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URANALYSB 



WILLIAMS 





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C.0P5(RIGHT DEPOSrr. 



PRACTICAL URANALYSES 



PEACTICAL 
URANALYSES 



^(^ BY 

B. G. E. WILLIAMS, M.D. 

DIRECTOR WABASH VALLEY RESEARCH LABORATORY. AUTHOR OF 
' ' L.\BORATORY METHODS, ^ ' ETC. 



ILLUSTFiATED 



ST. LOUIS 

C. V. MOSBY COMPANY 

1916 



t^^'^ 

"•^^n 



CoPYPiGHT, 1916. By The C. V. Mosby Comp^ 



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11 I I Press of 

'' The C. V. Mosby Company 

DEC -4 1916 ^'' ^""'^ 



©CI.A446701 



PREFATORY NOTE 



The "uranalysis should be regarded as a necessary 
part of every diagnostic examination. Until this is 
done, the sick man will be denied a large part of 
that which scientific medicine offers him. A 
period of renascence passes rapidly, and we see at 
hand a realization of the prophecy of Osier, ^^It will 
be done more and more when we send ont our stu- 
dents familiar by long practice with the use of the 
microscope and other instruments of precision." 

Where antilogia, or a combination of contradic- 
tory symptoms rendering diagnosis uncertain, has 
existed, we have wished to call in everything which 
medical chemistry, microscopy, and bacteriology 
have given us; and it may be ventured that until 
this situation has confronted the average practi- 
tioner, has he been willing to look to the laboratory 
for aid. Inasmuch as uracrasia, or a disordered 
state of the urine, is commonly met in disease, it 
is probable that the uranalysis is more frequently 
attempted than any other one piece of laboratory 
work. 

The most valuable uranalyses are not those for 
casts, blood and pus, but for the minor products ol 
erroneous metabolism and excretion — proofs of dis- 
turbed function and its nature in certain tissues, or- 

7 



8 PREFATORY NOTE 

gans and systems, while remedial measures may yet 
avail. This manual is not to be regarded as any- 
thing aiming at completeness, but as a guide for 
the student and practitioner, in those diagnostic 
matters likely to be encountered from day to day. 
Much emphasis has been placed upon findings often 
considered minor, and but little attention given to 
questions which might interest the specialist or re- 
search worker. The reader is, however, urged to 
study the larger books, if he would quickly gain 
the laboratory spirit. 

I have prepared these outlines, hoping to em- 
phasize many of the little points which are often 
lost in the complexity of the large book. 

B. G. R. Williams. 



CONTENTS 



CHAPTER I. PAGE 

Properties of the Normal Urine 13 

CHAPTER II. 
General Uranalyses 24 

CHAPTER III. 
Chemical Uranalyses 41 

CHAPTER IV. 
Quantitative Uranalyses 87 

CHAPTER V. 
Microscopic Uranalyses 104 

CHAPTER VI. 
Bacteriological Uranalyses 134 



ILLUSTRATIONS 



FIG. PAGE 

1. Apparatus Used in Uraualvses .... Frontispiece 

2. Urinometer 33 

3. Doremus-Hinds Ureometer 94 

4. Esbach Albuminometer 98 

5. Einhorn Saccharometer 100 

6. Sedimentation Glass 105 

7. Water Centrifuge 106 

8. Common Crystals Found in Urinary Sediments . . 109 

9. Urinary Sediments Ill 

10. Urinary "Sediments 114 

11. Some T^-pical Epithelial Cells From the Urinary 

Passages 120 



PRACTICAL URANALYSES 



CHAPTER I. 

PROPEETIES OF THE NOEMAL URINE. 

What the housewife knows today concerning the 
use of water in the removal of filth, Dame Nature 
learned many centuries ago in regard to animal 
and plant life. In the lower forms all the products 
of katabolism must be soluble to be eliminated, 
w^hether through the almost invisible pellicula of 
the ameba or the condensed cell wall of the bacil- 
lus. In the higher forms of life the removal of 
waste products of metabolism has been provided for 
by the kidney, intestine, sweat gland, and lung. In 
health, the highly differentiated cells of these struc- 
tures select with great care what substances they 
wish to excrete. That is to say while water is an 
important constituent of every excretion, urea is 
eliminated mainly by the kidney but bilirubin and 
indican never by the kidney. We find conditions 
much different in disease. Here the waste sub- 
stance cannot be excreted perfectly by the proper 
cells, and in consequence the duty falls upon others 
scarcely fitted for the work. This chapter has to 
deal with those substances which in perfect health 
are eliminated by way of the kidney. 

13 



14 PRACTICAL URANALYSES 

Normal Constituents of the Urine. — Normal urine 
must be regarded as an aqueous solution not only 
of certain products of katabolism but of substances 
which result from excess of foodstuffs. That is to 
say the solid constituents of the urine may be in- 
creased by overeating just as the water may be 
raised by drinking in excess, and the practitioner 
often loses sight of the fact that variations in the 
total solids are not always to be explained by dis- 
ease. The following table will give approximately 
the percentage composition of normal urine (urine 
of a person in health and upon a proper diet). As 
shall repeatedly be pointed out in this book, figures 
are based upon examination of twenty-four hour 
samples : 

Water 95% 

Solids 5% 

Urea 2.5% 

Other organic constituents 5% 

Inorganic salts 2. % 

Next to water, urea must be regarded as the most 
important constituent of the urine. It represents 
about eighty-five per cent of the total nitrogen elim- 
inated by the kidneys, which means over three- 
quarters of the proteid waste of the body. Urea is 
elaborated in the liver by a combination of carbon 
dioxid and ammonia, two exceedingly poisonous, 
katabolic products. Urea is scarcely poisonous, 
however, but is an active diuretic. It is quite solu- 
ble in water, and occurs in the urine in perfect solu- 



PROPERTIES OF THE ITORMAL URINE 15 

tion. For the clinical significance of urea variations 
and for calculations, see page 93. 

Other organic constituents of the urine are 
creatinin, uric acid, hippuric acid, and certain pig- 
ments. Uric acid occurs chiefly in the form of 
urates of sodium and potassium. 

The inorganic, or mineral constituents of the 
urine exist for the most part in the form of sodium 
and potassium salts. Thus we find such combina- 
tions with the chlorids, sulphates, phosphates, and 
so on. Under certain conditions, as variations in 
reaction or changes in diet, we may also find 
oxalates and carbonates. Likewise the sodium and 
potassium may be replaced in part in these combina- 
tions by calcium, magnesium, and ammonia, in 
which case the salts become less soluble or may even 
be precipitated before the urine is voided. For the 
actual amounts of the various constituents excreted 
each twenty-four hours, the reader is referred to 
page 88. 

Variations Due to Ammoniacal Fermentation. — 
A standing urine undergoes fermentation, usually 
of an ammoniacal character, though there may be 
some variations in the actual process, depending 
upon the type of bacteria causing the change, tem- 
perature and other influences not so well under- 
stood. There are other types of fermentation, but 
this being the usual one, it is well to study it some- 
what thoroughly that findings may be easily inter- 
preted. Ammoniacal fermentation is met with most 
commonly in voided, standing samples of urine. In 



16 PRACTICAL URANALYSES 

case there is retention of urine in the bladder, the 
same condition may occur. 

We have noted that urea, a complex and scarcely 
poisonous body, is elaborated in the liver from car- 
bon dioxid and ammonia, two very poisonous prod- 
ucts of katabolism. But it can in turn be broken 
down by unicellular forms of life into a number of 
simple products among which ammonia and carbon 
dioxid are chief. This is accomplished by a number 
of bacteria which elude classification; though it is 
probable that certain micrococci are most active in 
the process. 

At any rate carbon dioxid and ammonia are set 
free. The former may escape in part as gas, but 
usually unites in considerable amounts with such 
calcium as may be present, to form minute, insoluble 
spheres of calcium carbonate. The ammonia and 
ammonia-like bodies as well as nitrogen, escape into 
the air. It is to these bodies that the urine owes its 
vile odor. Some of the ammonia gas remains in so- 
lution in the water or in the form of ammonium 
carbonate and. gives to the urine its volatile alka- 
linity. Finally some of it unites with the urates to 
form the cockle burs of ammonium urate, while 
some combines with the phosphates to form the 
coffin-lid crystals of ammonio-magnesium phosphate. 
These various forms of crystals will be described 
under the microscopic uranalyses, page 109. These 
changes are not to be regarded as pathological un- 
less it is evident that they have occurred before the 
urine was voided. In the examination of all speci- 



PROPERTIES OF THE NORMAL URINE 17 

mens this point should be determined. The presence 
of pus and bladder cells along with the above find- 
ings, speaks for ''alkaline cystitis/' To urines sent 
for examination to distant laboratories a single lump 
of gum-camphor or thymol should be added, and this 
advice holds especially for the summer months. In 
hot weather a lump of gum-camphor should be 
placed in the urinal before beginning the collection 
of the specimen. Scalding out the urinal just before 
the sample is collected will kill all bacteria present 
and delay the fermentation. 

Variations Due to Diet. — The amount of water 
varies to a certain extent with the amount which 
has been taken into the body before and during 
the twenty-four hours the urine has been col- 
lected. The man who drinks but little is not likely 
to pass normal amounts of urine, and the vice versa 
rule holds within certain limits. The author has 
witnessed cases in which excessive water drinking 
did not dilute a concentrated urine, though it was 
very likely that truly pathological processes played 
a part in every case. A meat diet is likely to keep 
the urine acid, a strictly vegetable diet may render 
it alkaline. Diet plays a not unimportant role in 
the determ;ination of the solid composition of nor- 
mal urine. When the diet is excessive, there will 
quite likely result an increase of all the solids or 
certain of the solid constituents. This is easily un- 
derstood when we recall that the solid matter of the 
urine is furnished quite as much by the decomposi- 
tion products of this foodstuff excess as by the 



18 PRACTICAL URANALYSES 

metabolic processes. Thus there may be an increase 
of urea, of the urates, chlorides, phosphates and 
even the oxalates. In certain conditions the pro- 
teid foodstuffs when excessive, undergo fermenta- 
tion in the bowel, and add to the urine, indican and 
other bodies which cannot be regarded as strictly 
normal urinary constituents. A vegetable diet is 
likely to increase the oxalates and carbonates, while 
a meat diet is likely to increase the chlorides, phos- 
phates, and nitrogenous bodies. Certain berries 
have been claimed at times to influence the color of 
the urine, and certain foods, especially asparagus, 
undoubtedly contribute to its odor. 

The taking of meals has considerable effect upon 
the urinary composition and especially upon its re- 
action from hour to hour; but since we are con- 
cerned mainly with the question of a twenty-four 
hour sample, it is certainly not worth the while to 
dwell upon these considerations. In the matter of 
alimentary albuminuria and glucosuria, see pages 
44 and 64. 

Variations Due to Exercise. — After continued vio- 
lent exercise accompanied by profuse perspiration, 
the amount of urine may be reduced. This is not 
always true for the reason that the person is likely 
to drink larger amounts of water at this time. The 
urinary nitrogen (urea, uric acid, ammonia, etc.) is 
but little influenced by exercise, inasmuch as body 
proteids rather than carbohydrates are utilized. It 
is known, however, that muscular exertion will in- 
crease the phosphates. 



PROPERTIES OF THE NORMAL URINE 19. 

Variations Due to Temperature. — It is observed 
that the amount of urine is usually increased in 
winter, or at least when there is a sudden change 
from warm to cold weather. This is explained by 
the fact that there is a certain amount of water to 
excrete, and in case the perspiration is reduced, the 
extra work falls upon the kidneys. These varia- 
tions are not always striking inasmuch as man 
drinks much more water during hot weather than 
cold. Amorphous sodium and potassium urates are 
less soluble in cold than warm urine, and so they 
often deposit soon after the urine has been voided. 

Variations Due to Medication. — The amount of 
urine is increased by diuretics and decreased by cer- 
tain drugs as mercury when given in excess. It is 
also diminished secondarily by pilocarpin owing to 
the increased perspiration. It has been found that 
glucose injected into the blood will increase the 
amount of urine, and this may explain the polyuria 
of hyperglycemia. The reaction of the urine may 
be altered almost at will. Thus boric and benzoic 
acids and diacid sodium phosphate increase the 
acidity while the carbonates, citrates and acetates 
will render the urine alkaline. The odor may be 
altered by such drugs as asafetida, valerian, and 
many of the volatile oils. The urine may be dark- 
ened by the coal tar derivatives, rendered blue or 
green by methylene blue, or red by sulphonal, tri- 
onal, antipyrin and related preparations. 

Drugs may be regarded as possible sources of er- 
ror in almost all the chemical uranalyses, and the 



20 PRACTICAL URANALYSES 

physician must by all means constantly keep this 
fact in mind. Thus serum albumin may be simu- 
lated by the resins, glucose may be counterfeited by 
decomposition products of the aromatic derivatives, 
diacetic acid may be confused with salicylates and 
indican Avith iodid of potash. These points will be 
considered along with the sources of error and dis- 
cussed under the respective chemical uranalyses. 

Variations Due to Preservation. — It is often nec- 
essary to preserve urinary specimens for several 
hours before they can be examined. This may be 
done very successfully, but the worker must keep in 
mind several sources of error in this connection. 
For example the author has the following incident 
to report. A urine which was believed to contain 
the indicans did not give a positive reaction. Fi- 
nally it was noted that several drops of chloroform 
had been added and rested upon the bottom of the 
container. Accordingly the specimen was thor- 
oughly mixed and other samples were examined. A 
prompt indican test was the result. 

Formaldehyd should not be added to urinary 
specimens for the purpose of preservation. There 
are several reasons for thi«. It is likely to precipi- 
tate in part the serum albumin if present. It hard- 
ens and renders brittle some of the organized micro- 
scopic elements. 

Complaint ma}^ be had of chloroform for the rea- 
son that it appears to dissolve some of the hyalins. 

The author is of the opinion that the most excel- 
lent urinary preservative is a single lump of thymol. 



PROPERTIES OF THE NORIVCAL URINE 21 

Enough of this dissolves in the urine to preserve it 
for several days. It will not stop fermentation quite 
so easily as it will prevent it, so that it may be 
placed in the clean urinal at the beginning of the 
collection. Now and then enough thymol is dis- 
solved to simulate a merest trace of serum albumin, 
in which case it is advisable to add an equal volume 
of nitric acid and heat again. If serum albumin, 
the precipitate will persist; but if thymol, will dis- 
appear. 

Variations Due to Contaminations. — Urines may 
be contaminated by accident or by intention. In 
the former case we have usually to deal with cot- 
ton, linen or woolen fibers which may be mistaken 
for casts or cylindroids. Starch grains, common 
dirt, vegetable cells and other substances may be 
found when the specimen is centrifugalized, and the 
skilled worker may become so accustomed to ignore 
them that he will scarcely note their presence. Fat 
droplets are likely to be contributed by the smegma 
or catheter grease. Pus, blood, bacteria and various 
epithelial cells may be explained by vaginal contam- 
ination; and this is a very common source of error 
in the experience of the author. 

The questioning must ofttimes be close in case of 
questioned glucose reactions. These have been 
noted when the specimen was submitted in syrup 
bottles or in tablet triturate bottles (lactose). 

Hector Gavin once said, '^As all animals have 
been classed into devouring and devoured, man 
holding a somewhat commanding position in the 



22 PRACTICAL URANALYSES 

first of these; so may human beings be considered 
under the two comprehensive heads of deceivers 
and deceived. ' ' Man has added almost every house- 
hold article to his urine hoping to deceive the chem- 
ist. From the overworked sugar bin he has often 
turned to scratch the rust off the kitchen stove for 
uric acid crystals. Many of these attempts are 
crude and ridiculous, but it is well to be on the alert 
for them. 

Sham Abrahaming is not always at the bottom of 
intentional tampering with the urine. Women have 
been known to add perfumes or even sugar to their 
urine before submitting it for examination to a 
physician with whom they were acquainted. 

Variations Due to Other Causes. — The man who 
does considerable insurance work should satisfy 
himself that the sample of urine submitted has been 
voided by the applicant. A bottle of saffron tinted 
water will cause no difficulty if the specific gravity 
is taken. But more likely the person attempting 
fraud will submit a specimen from a healthy indi- 
vidual. In case of question it is well to complain 
concerning the specimen and ask that he void an- 
other into a special receptacle. 

Pathological conditions may furnish specimens 
which may confuse the man who knows nothing of 
the clinical history. Thus in late interstitial 
nephritis, the kidneys may be passing but little save 
water ; the author has received such specimens with- 
out instructions and has been at a loss whether to 
attempt a uranalysis or a sanitary examination of 



PROPERTIES OF THE NORMAL URINE 23 

drinking water. In such case it is often advisable 
to test for some normal urinary constituents which 
may be detected in very small amounts. Creatinin 
may usually be found by adding a little aqueous 
picric acid and a few drops of dilute sodium hy- 
drate which will produce an intense red color even 
if creatinin is present only in one-fifth the normal 
amount. Eapid and repeated centrifugalization be- 
ginning with large volumes of the specimen may 
eventually reveal typical cells if not true casts. 



CHAPTEE II. 
GENERAL URANALYSES. 

Collecting the Specimen. — The examination of a 
single voiding of urine may give sufficient informa- 
tion in occasional instances, but as a rule it will not. 
The quantitative work is hopelessly impossible save 
when samples from a twenty-four hours' quantity 
are examined, because as we have shown the actual 
composition varies from hour to hour. At certain 
hours of the day, diabetic patients may pass no 
glucose. At other hours perfectly healthy individ- 
uals may pass small amounts of glucose. At certain 
hours icteric patients may pass no bilirubin, pa- 
tients with valvular or kidney lesions will pass no 
serum albumin and patients with liver disease will 
pass no urobilinogen. Lung patients will pass no 
urochromogen, typhoid patients will pass no diazo 
bodies, patients with enteroptosis will pass no in- 
dican, pancreatic patients will pass no acetone. A 
person apparently normal in health may pass no 
urea for several hours ; and indeed from a specimen 
taken at random, conclusions may be impossible, or 
if based upon impressions gained from such an* in- 
vestigation, may be dangerously misleading. The 
acidity varies from hour to hour. It may be quite 
impossible to fix a proper relation between symp- 
toms and microscopic elements as crystals, casts, 

24 



GENERAL URANALYSES 25 

cells and so on. It is well known that a shower of 
tube casts may follow the convulsions of brain tu- 
mor, but they might be absent at other times. Ex- 
amination of the single specimen might lead to the 
diagnosis of nephritis. 

Instruct the patient to empty the bladder at noon 
and to reject this sample. From this point he 
should save all urine to and including that passed 
the following noon. Special diets are not advisable 
but he should eat and drink that to which he is ac- 
customed. In case either the vegetable or meat diet 
be excessive, note should be made of this as well as 
of any medicines he may be taking. Measure ex- 
actly the total quantity and keep record of this fig- 
ure. Then mix gently the entire specimen so that 
the sediment may be saved. If there is but little 
sediment, it may be well to pour off some of the 
supernatant liquid before mixing. From the mix- 
ture, several fluid ounces are used for the examina- 
tions. It is best during the summer months to drop 
a lump of thymol into the clean urinal as soon as 
the collection is begun. Gum-camphor serves less 
well but can be used. If the specimen is sent to a 
laboratory for an examination, it should be placed 
in a clean bottle and a lump of thymol added. 

Amount. — The statement that the normal urinary 
output varies greatly is not correct. It is reason- 
able to assume that the .amount voided during a 
given twenty-four hours may be double that of the 
same time preceding and yet compatible with per- 
fect health ; but if the urine falls beloAv tAventy-f our 



26 PRACTICAL URANALYSE3 

fluid ounces or rises above sixty fluid ounces for 
considerable periods of time, it must eventually be 
explained upon pathological grounds, is the experi- 
ence of the author. Most laboratory workers re- 
gard forty-eight fluid ounces per twenty-four hours, 
as an average for the person in excellent health and 
with good habits. We have spoken of the quantita- 
tive variations due to diet, temperature, exercise, 
and medicines, so let us consider what influence 
disease bears to the daily amount of urine. It must 
be constantly borne in mind, however, that all phys- 
iological factors are to be ruled out before turning 
to pathological explanations. 

First of all is to be considered the pathological 
polyurias. When the polyuria is likewise a noc- 
turia, that is, when the condition is more marked 
during the night, our attention is often directed to- 
ward the arterial system and the possibility of hy^- 
pertension. Upon the other hand, it may be re- 
marked that when the arterial tension is low and 
venous congestion exists, as in the cardiac valvular 
lesions, there may be a marked oliguria. The par- 
oxysmal polyurias are doubtless of vasomotor or- 
igin, while the polyuria of diabetes may be ex- 
plained by the fact that glucose is a true diuretic 
when it occurs in the blood in more than normal 
amounts. Diabetes insipidus often eludes classifi- 
cation from an etiological standpoint. Certain of 
the cases may be examples of urina pohiSy or poly- 
uria due to excessive taking of liquids, and an in- 
vestigation of the habits of the patient, will furnish 



GENERAL URANALYSES 27 

the proof. Others are undoubtedly examples of 
syphilitic nephritis ; but some we cannot explain. A 
polyuria occurring in nephritis, speaks for inter- 
stitial involvement, whereas an oliguria points to 
parenchymatous lesion. Polyuria associated with 
high urea may be explained by the fact that for 
some reason there is an overplus of urea, and that 
urea like glucose, is an excellent diuretic. Such 
conditions have been termed azoturia. 

Scanty secretion of urine when persistent, must 
be regarded as a very important condition, no mat- 
ter what the cause, for it is not unreasonable to sup- 
pose that serious damage to the kidney parenchyma 
is likely when the urine is overconcentrated for long 
periods of time. In addition to those causes which 
we have considered above, may be mentioned severe 
fevers, diarrhea, and hemorrhages. When the urine 
becomes very co^centrated, the precipitation of cer- 
tain crystals from solution is favored. Such precip- 
itation in vivOf occuring for extended periods of 
time, may lead to irritation, pain or hemorrhages 
from the urinary passages (see oxaluria dolorosa, 
page 110). 

Oliguria may be due to decreased urea elabora- 
tion. Urea is chief of the physiological diuretics. 
Thus in hepatic cirrhosis, passive congestion of the 
liver, and so on, the stupefied hepatic parenchyma 
fails to synthesize urea to produce the daily three 
pints of urine. 

Color. — When pathological coloring matters are 
absent, the hue varies directly with the dilution. 



28 PRACTICAL URANALYSES 

Normally we expect the color to approximate that 
of brass. In the highly diluted urines, there may 
be absence of color; and when the urine is highly 
concentrated, the color may approach that of cop- 
per. We have seen how the color may be influenced 
by foods and medicines. 

Certain pathological pigments may impart an in- 
tense color to the urine. While the color may sug- 
gest the pigment, a final decision would not be safe 
without proper chemical tests. A port-wine color 
may suggest hematoporphyrin ; a red urine, hemo- 
globin or methemoglobin ; a black urine, melanin ; a 
green urine, biliverdin; a golden urine, bilirubin; 
and a blue urine, indigo. Practically all of these 
colors may be given by drugs and foods, so let it be 
repeated, chemical proof is ahvays necessary. 

Some urines, especially those containing alkapton 
bodies, decomposition products of salicylic acid and 
carbolic acid and even melanin, turn black upon 
standing. 

Odor. — The urine may possess no odor Avhatever, 
and this especially holds when the specimen has 
stood for an hour or so. When the bottle contain- 
ing the sample is tightly corked, the normal odor 
may be preserved for days. The odor of normal 
urine is not unpleasant, and slightly resembles 
bouillon, though quite characteristic. A concen- 
trated urine is more odoriferous as a rule than is a 
dilute one. We have stated that the urine may vary 
somewhat with the diet and with medication. The 
volatile aromatics to which the urine owes its nor- 



GENERAL ITRANALYSES 29 

mal odor have not been identified and classified. It 
has been claimed that one substance, urinod, may 
be held to account for the normal odor. In highly 
acid urines where hexamethylenamin is being given 
in large doses, a faint odor of formaldehyd may be 
detected. Preservatives may impart to the speci- 
men an odor which obscures the normal urinous 
odor. Fermentations give rise to the stinks so com- 
monly noted in unclean urinals. The most common 
of these has been considered, and furnishes ammo- 
nia and volatile ammonia-like bodies. The author 
has been accustomed to speak of the typical odor of 
ammoniacal fermentations as that resembling a 
mixture of ammonia and stewed turnips. At times 
the odor of the urine may give the impression that 
we are dealing with fecal fistula because of the pres- 
ence of hydrogen sulphid. But it must be kept in 
mind that certain bacteria may break up the uri- 
nary sulphates, and no true connection need be pres- 
ent between bowel and urinary tract. 

The redolent odors of diabetic urine have been 
said to resemble new-mown hay, cider, molasses and 
so on, but such odors are due mainly to acetone and 
its congenors rather than to glucose. 

General Appearance. — The same cautions which 
have been ventured in regard to the color may be 
repeated at this point; viz., that conclusions from 
the appearance alone are unsafe, proper chemical 
and microscopical examinations being necessary in 
every case. 

A urine may be almost clear when voided; but 



30 PRACTICAL URANALYSES 

after standing for a short time, one or more of sev- 
eral possible alterations occur. First of all, a floc- 
culent deposit may collect near the bottom, and 
upon examination be found to consist of a network 
of viscid, gelatinous threads composed mainly of 
mucus; and suspended in the interspaces, variable 
numbers of cellular elements, mainly leucocytes and 
epithelial cells. The nubecula is more marked in 
concentrated urines than in dilute ones, and is more 
marked in females, the mucus and epithelium being 
contributed in large part by the vagina. 

Almost any of the urinary sediments may occur 
in amounts sufficient to cloud the urine. In health 
we find the orange, pink or white urates, which may 
also precipitate when the standing urine cools, and 
be easily redissolved by heating. 

The voiding of phosphatic sediments is somewhat 
rarer in perfect health though not impossible. The 
earthy phosphates may be precipitated in the urin- 
ary tract by any factor which tends either to in- 
crease the phosphates or alkalinize the urine. They 
may be quickly precipitated in the standing urine 
by loss of acidity, usually through fermentation. 
Unlike the amorphous urates with which they are 
usually confused, they are not dissolved but precip- 
itated by heat. They go quickly into solution when 
the urine is rendered acid. 

The presence of triple phosphates (ammonio- 
magnesium phosphates) in the freshly voided urine, 
is proof that for some reason the bactericidal prop- 
erties of the lining of the urinary tract have been 



GENERAL URANALYSES 31 

lowered sufficiently to permit the growth of sap- 
rophytes and consequent ammoniacal fermentation. 
In some cases there may be an exception to the 
above rule, for a few crystals of ammonio-magne- 
sium phosphate may occur with a fixed alkalinity. 
These crystals (coffin-lids or prisms) are very heavy, 
and sink much more quickly to the bottom of the 
vessel than do the amorphous urates or earthy phos- 
phates. The phosphates are sometimes mistaken for 
true pus. It must be held in mind that a chemical 
test is not always sufficient to distinguish for the 
following reason. Heat and nitric acid may appar- 
ently clear a sediment and thus apparently prove 
phosphates. But the microscope will show that 
traces of pus also existed. 

Uric acid is likely to occur as a brown or heavy 
red sediment alone or in connection with the amor- 
phous sodium and potassium urates. It m'ay be 
present even when the urine is fresh in connection 
with a high acidity. The crystals are dissolved with 
some difficulty and preserve their form as a rule so 
long as the urine remains unchanged. AVith the 
change in reaction coincident with ammoniacal fer- 
mentation these crystals are often replaced by the 
envelopes of lime oxalate. 

Calcium oxalate in its various crystalline forms 
but usually as typical quadratic octahedra is a not 
uncommon sediment which may contribute to the 
urinary cloudiness. It may sink to the bottom of 
the vessel, but very frequently the crystals remain 
suspended in the nubecula, the entire mass some- 



32 PRACTICAL URANALYSES 

times rising to the surface as a scum. Fermentation 
plays an important role in the deposition of the 
crystals in old specimens. We have learned that in 
painful oxaluria (oxaluria dolorosa) these crystals 
may appear in the freshly voided urine. 

Much more rarely do ammonium urate, calcium 
carbonate, calcium sulphate, c^^stin, leucin, tyrosin, 
xanthin, and similar sediments occur as crystals or 
amorphous collections in amounts large enough to 
give ^individuality" to a urinary cloudiness, 
though they ma}' accompany certain of those men- 
tioned above. Now and then a sediment may be 
found, which is made up almost wholly of dicalcium 
phosphate rosettes (stellar, or neutral phosphates) 
or of ammonium urate cockle-burs. Cholesterin is 
very rarely found even in very diligent microscopic 
investigation. When cystinuria occurs, calculus 
formation is almost inevitable. 

The urine may be clouded b}^ pus, blood, epithelial 
collections, mucus, spermatozoa, fat droplets, and so 
on, which may be confused with the inorganic sed- 
iments or with each other. Now and then a urine 
may be examined in which albuminous granules or 
casts or both may give the specimen a distinct 
cloudiness. Large numbers of bacteria may impart 
to a specimen a dense fogginess. 

Specific Gravity. — The specific gravity varies nor- 
mally between 1012 and 1025, being high or low in 
health according to the concentration of the urine. 
In apparent health the specific gravity may rise 
above or fall below these limits. In such case other 



GENERAL URANALYSES 



33 



/n 



examinations should be made, for it is very likely 
that such readings when persistent, are incompat- 
ible with health. That is to say, a specific gravity 
persisting below 1010 in a mixed 
twenty-four hour specimen, should 
suggest careful inquiry as to the 
amount of urea and so on; or 
when the specific grarvity fails to 
fall below 1030, may suggest a 
lack of water in the urine or over^- 
plus of some one or several con- 
stituents, the latter possible strict- 
ly pathological. Tn diabetes in- 
sipidus and in interstitial nephritis 
there is a persistent polyuria with 
a low specific gravity; while in 
diabetes mellitus and azoturia, 
there is likewise a persistent poly- 
uria, but a high specific gravity. 
In parenchymatous disease of the 
kidney the specific gravity is high, 
while the total amount per twen- 
ty-four hours is likely to be re- 
duced. When high specific grav- 
ity occurs without polyuria, there 
is a tendency upon the part of the 
difficultly soluble salts to precipi- 
tate out, and such precipitation 
can be prevented only by other factors as excessive 
acidity and so on. 

For routine v^ork temperature corrections are 



^45- 



--22^ 




Fig. 2. — Urinometer 



84 PRACTICAL URANALYSES 

scarcely necessary if the technic is carried out with 
specimens which have neither been cooled nor 
heated. 

For the specific gravity estimation we use the 
urinometer, a special hydrometer. The following 
cautions must not be overlooked when estimating 
the specific gravity: 

1. The cylinder should not be filled over four- 
fifths or some of the urine will be displaced by the 
urinometer. 

2. If foam is present on surface, remove by a 
piece of filter paper or blotter before placing the 
urinometer in the cylinder. 

3. The urinometer must not come in contact with 
the inner surface of the cylinder but must float free 
near the center of the sample. Contact with the 
cylinder may be avoided to some extent if the urin- 
ometer be given a slight twirl just as it is placed in 
the urine. 

4. Make reading from the lower meniscus. 

In case the amount of urine is small and a specific 
gravity reading is considered more desirable than 
other examinations, the sample may be diluted with 
distilled water and a reading taken. The last two 
figures of this reading multiplied by the dilution 
will give the correct specific gravity. 

Reaction. — The Avorking methods of the various 
laboratory authorities vary so hopelessly in respect 
to selection of indicator, classification of bodies to 
which reactions are due, clinical significance of find- 



GENERAL URANALYSES 35 

iiigs and so on, that this book cannot hope in its 
available space, to attempt a review or reconcilia- 
tion, but merely to give in brief, a resume of the 
views and working technic employed by the author. 
It is well to warn the reader that while some of our 
workers have given too little attention to the reac- 
tion of the urine, others have perhaps gone too far. 
A large amount of information concerning the diag- 
nostic and therapeutic problems of reaction have 
been omitted in order to emphasize essentials. 

Certain workers have shown that free organic 
acids are present in the normal urine, or at least in 
some apparently normal urines ; but the observation 
is doubtless inconsequential so far as clinical pur- 
poses are concerned. The normal urinary acidity is 
due almost entirely to certain acid salts especially 
diacid sodium phosphate, and such traces of free 
acid as may be detected by the sensitive (not clin- 
ical) methods, may be ignored. At any rate it is 
true that neither uric acid nor acetone series con- 
tribute to the normal urinary acidity. 

AVhile single specimens of normal urine may be 
alkaline, it is rare that the mixed twenty-four hour 
excretion is ever alkaline. If such is the case, an in- 
quiry concerning the diet will usually provide an 
explanation. With phenolphthalein (an indicator 
which like all others has its shortcomings, but which 
is best for accurate w^ork) practically all normal 
urines are acid. 

Urinary hyperacidity which cannot be explained 
by diet or medicines must always be regarded as 



36 PRACTICAL URANALYSES 

pathological. Most commonly this hyperacidity 
may be explained either by the presence of certain 
microbes associated with the putrefaction of proteid 
foodstuffs (usually in colon) or associated with the 
decomposition of body protoplasm. Into a third 
class fall those hyperacidities due to vicious 
katabolic processes in the body cells. In the first 
case, we have to deal with intestinal toxemia, a proc- 
ess but partially understood ; in the second with true 
infection in tissue or organ and which may be lo- 
cated with difficulty even when suspected; and in 
the third, with diseases of metabolism especially the 
acidoses of children and true diabetes. In the first 
case we have to deal with scarcely pathogenic bac- 
teria which produce acids and acid-like bodies by 
excessive and erroneous putrefaction of proteid 
foods, and such acids can occur in the urine only 
after absorption from the bowel. 

The fact must not be lost sight of that a urine 
may not be hyperacid \rhen secreted by the kidney 
but become so in infections of the urinary tract. 
Thus in colipyelitis or in tuberculous kidney, it is 
not unusual to find the so-called ^^ scalding urines.'' 
Now and then we have to deal with hyperacid 
urines where an explanation seems impossible, as 
for example in the uricacidurias where excess acid- 
ity is coincident to (though not caused by) uric 
acid. 

Estimation of Acidity. — For practical purposes it 
is not necessary to carry out the various estimations 
of mineral and organic acids. We are rather inter- 



GENERAL URANALYSES 37 

ested in the question of total acidity to determine if 
possible whether the specimen is or is not exces- 
sively acid. The titration methods are used in the 
larger laboratories where much of this work is to 
be done. For the occasional estimation, the method 
of narrower is both simple and fairly accurate. 

Instead of adding the alkali from a graduated 
buret, the urine and indicator are placed in a grad- 
uated test tube and to this the alkali is added drop 
])y drop from a pipet. 

The urine is poured into the acidimeter until the 
lower meniscus reaches the 10 c.c. mark. A few 
drops of phenolphthalein are added. Then by 
means of a pipet or medicine dropper, decinormal 
sodium hydrate solution is added drop by drop. 
After each drop is added the tube is shaken or in- 
verted so that the contents are thoroughly mixed. 
When the first permanent pink occurs, the acidity is 
read off in degrees as marked by the lower menis- 
cus. The normal acidity of a mixed tAventy-four 
hour specimen averages between 30-40 degrees. Es- 
timations must of course be made only from mixed" 
twenty-four hour specimens which have been kept 
sw^eet by refrigeration or preservatives. For we have 
shown that the reaction of the urine varies somewhat 
from hour to hour and is altered by urine decom- 
position. An acidity of 50 degrees may not be 
strictly overplus, but anything above that must be 
regarded as pathological. 

Pathological Hyperacidities. — Briefly these may 
])e classified : 



38 PRACTICAL URANALYSES 

1. Copremic Hyperacidities. — This has been dis- 
cussed. We are not certain as to the exact nature 
of all the acids. Among them have been found 
indolacetic acid, unknown acids containing sulphur, 
paraoxyphenylacetic acid, paraoxyphenylpropionic 
acid and so on. Likewise we may find the indicans 
(red or blue), phenol, paracresol and similar bodies. 
In the opinion of certain workers, much of the am- 
monia which normally goes to form urea may be 
used instead to neutralize the acids that the fixed 
alkalies of the tissues may be spared. At any rate 
the urea may be low without reduction of the nitro- 
gen, and examination will show a high ammonia. It 
is not in the scope of this book to consider the symp- 
tomatology of copremia. We have come to believe, 
iiowever, that long continued acidemia* must be an 
important cause of nephritis. Indeed we have found 
that traces of serum albumin and hyalin casts are 
quite likely to accompany hyperacid urines and sug- 
gest nephrosis. Moreover Martin Fischer and oth- 
ers have shown that acid retention in the renal 
parenchyma, is an important factor in the retro- 
grade changes and desquamation of the ultimate 
secreting kidney unit. 

2. Pyemic (Infectious) Hyperacidities. — The 
pathological process is similar if not identical with 
the above. In the manufacture of the poisonous 
acids, tissue protoplasm rather than proteid food- 



*The use of the term "acidemia" has been challenged (Jour. Am. 
Med. Assn., Vol. Ixvi, No. 5, p. 376). It has been used in this 
connection, not to indicate the reaction of the blood, but of the urine, 
and for want of a better term. 



GENERAL URANALYSES 39 

stuffs are utilized. The lesion may be but a simple 
nephrosis, but we have good reason to believe that 
eventually a point may be reached where hopeless 
and progressive nephritis results. The focus of in- 
toxication may be easily found in some cases. More 
likely we are dealing with a low grade of chronic 
infection hidden away, and local symptoms may be 
absent. Thus purulent and necrotic processes may 
be concealed in the nasal* sinuses, teeth, tonsils, 
lymph glands, old lung cavities, gall bladder, ap- 
pendix, prostate gland, and so on. 

3. Hyperacidities of Acidosis. — Recently it has 
been learned that acidosis may occur without true 
diabetes, especially in children, after anesthesia and 
so on. Betaoxybutyric acid, acetone, diacetic acid 
and other unknown bodies may be present in the 
urine. 

4. Local Hyperacidities. — A urine when secreted 
may be normal in reaction but become hyperacid be- 
fore reaching the meatus urinarius. Where exces- 
sive acidity is due to bacteria, the renal parenchyma 
doubtless escapes injury from such acids. It is well 
known that in renal phthisis, the urine may become 
very highly acid before pus appears. In colon 
bacillus infection of the renal pelvis, acid formation 
is quite the rule. It would appear from the investi- 
gations of the author that now and then we have 
to deal with urinary hyperacidities due to unknown 
fermentation processes. This is seen in the bene- 
ficial influences of urotropin in some of the painful 
oxalurias associated with excessively acid urine. 



40 PRACTICAL UR ANALYSES 

5. Cryptogenic Hyperacidities. — High acidity 
often accompanies the presence of uric acid crystals 
in the urine. It is also due to unknown processes 
of fermentation in the urinary tract. At least we 
believe that uric acid does not of itself contribute to 
the acidity of the urine, but that the whetstone 
formation is consequent. 

Pathological Hyperalkalinities. — A persistently 
alkaline urine (twenty-four hour mixed specimen 
examined when fresh) cannot be regarded as phy- 
siological : 

1. Fixed Hyperalkalinities. — Persistent alkalin- 
ity which is not due to ammonical fermentation may 
usually be explained by medication or diet. AVe be- 
lieve that vicious katabolic processes are never 
alkaline but invariably acid producing. The ab- 
sorption of large exudates or transudates has been 
claimed to have rendered the urine alkaline. 

2. Volatile Alkalinity. — This state is doubtless 
ahvays pathological. A freshly voided specimen 
must be examined. High ammonia with low urea 
and no pus or symptoms of cystitis may point to 
hepatic lesion. However the damage to the liver 
parenchyma may be very great without disturb- 
ances of the urea function. 

The term volatile alkalinity is usually reserved 
for the urines of those diseases of the bladder ac- 
companied by partial urinary retention or other 
condition favoring fermentation of an ammoniacal 
type. Pus, blood, vesical cells, and hosts of bacteria 
usually are found. 



CHAPTER III. 
CHEMICAL URANALYSES. 

It may be stated that as a rule the urine should 
be filtered before undertaking the chemical tests. 
There are exceptions, especially where a single test 
for glucose or serum albumin is made upon a clear, 
freshly voided urine. The rule holds very rigidly, 
however, in case the urine is not perfectly trans- 
parent. In the albumin tests, clear and untreated 
samples should always be set up as controls unless 
the worker has considerable experience in detecting 
traces. 

A clean glass funnel and clean filter paper are 
used. In some instances it may be impossible to 
clear the urine by filtration, even though several 
thicknesses of filter paper are used. In case this 
cloudiness is due to bacteria, it may be impossible 
to decide whether serum albumin is or is not pres- 
ent. The urine should be shaken with calcined mag- 
nesia and filtered or recourse be had to other 
samples. But if the cloudiness is due to earthy 
phosphates or amorphous urates, the heat and 
nitric acid test will clear this up. Any urinary 
cloudiness which cannot be removed by filtration, 
and which cannot be explained by the presence of 
hosts of bacteria, is in all likelihood due to these 
inorganic sediments, and when testing for serum 

41 



42 PRACTICAL URANALYSES 

albumin, the heat and nitric acid tests will decide. 

Euglobulin. — To 5 c.c. of clear urine, are added 
about 20 c.c. of cold distilled water and then a drop 
of glacial acetic acid. Set up alongside a control 
of clear, untreated urine. The mixture may be 
shaken but not heated. After a short time a cloudi- 
ness may be noted. This is due to euglobulin 
(nucleoproteids). 

When a slight albuminuria (as determined by the 
heat and nitric acid test) proves to be a euglobulin- 
uria (as determined by the above reaction) it is very 
likely that we are not dealing with true serum albu- 
min. This point should be held in mind when test- 
ing for the trace of albumin. 

There is a tendency upon the part of clinicians to 
regard euglobulinuria as a benign albuminuria and 
significant of true body defenses; i. e., combinations 
of neutralizing proteids with acids (nucleinic, sul- 
furic, taurocholic, etc.) ; and they are excreted by 
the kidney as waste products of metabolism. Often 
we are able to dispose of the diagnosis of possible 
nephritis by means of this test, although such a dis- 
posal is not made by life insurance companies who 
look upon all albuminurias as bad risks. Many if 
not all of the functional albuminurias are euglobu- 
linurias, and as will be shown later, all of the serum 
albuminurias are distinctly pathological. The trace 
of albumin accompanying excess of indican, is 
usually euglobulin and may be explained by the 
excess of organic acids accompanying the indican, 
although serum albumin sometimes may be found in 



CHEMICAL URANALYSES 43 

indicanuria and here suggests actual damage to the 
renal parenchyma. Euglobulin is sometimes found 
in apparently healthy individuals and in the ab- 
sence of other urinary changes, but euglobulin 
though not to be taken as evidence of renal lesion 
is perhaps at least semipathological. Euglobulin is 
suggested when an excess of the nitric acid clears 
up a *^ hesitating" cloudiness. 

At least one source of error must be kept in mind 
when applying the euglobulin test. In diseases of 
the renal pelvis, ureter and bladder, there is an in- 
crease of the nucleoproteids ; and the reaction to 
acetic acid may closely simulate euglobulin. In the 
presence of such lesions and especially when pus 
is present, the test cannot well be applied. 

Eecently PoUitzer seems to have advanced a step 
further in the explanation of some of these acetic 
acid reactions. It has been known that chondroitic 
acid when added to the urine along with a drop of 
acetic acid will coagulate serum albumin. Upon 
the other hand chondroitic acid may occur in urines ; 
and in the presence of serum albumin even though 
in traces, may be precipitated out by acetic acid. 
Furthermore if serum albumin is not present in the 
sample, by adding small amounts along with the 
acetic acid, large precipitates may occur in the night 
urines of orthostatic albuminurias, urines of tonsil 
infections, and so on, all of which have been shown 
to contain other organic acids. It is likely if Pol- 
litzer's observations are confirmed, that we will ar- 



44 PRACTICAL URANALYSES 

rive very closely to an explanation of certain albu- 
minurias as yet but little understood. 

Serum Albumin, Significance. — Serum albumin, 
or true albumin must be regarded as a pathological 
finding, at least when it occurs persistently in the 
urine. Its diagnostic and prognostic significance de- 
pend upon other urinary findings and upon other 
clinical data, rather than upon the actual amount 
which may be present from day to day. The author 
has observed cases in which serum albumin has oc- 
curred in rather large amounts for years. These 
patients are enjoying relatively excellent health, 
but of course not perfect health or prospects. Upon 
the other hand mere traces have been found in the 
rapidly fatal cases of Bright 's disease. Clinically 
we adhere to old classifications, mainly because 
every albuminuria cannot be properly placed by 
the pathologist. From the standpoint of the lat- 
ter, the following classification would be excellent 
Avere we but able to place each given albuminuria 
into its proper class or to tell just when, for ex- 
ample, an albuminuria of the first classes becomes an 
albuminuria of the C or D type. 

Class A. — Albuminurias due to overplus albumin 
content of the blood including the alimentary 
albuminurias. It seems probable that there 
are many types of serum albumin, and that 
the amount in the blood need not be espe- 
cially great, but the proteid be abnormal in 
composition, so far as the needs of the body 
are concerned, for excretion to occur. 



CHEMICAL URANALYSES 45 

Class B. — Albuminurias due to disturbances of 
' nutrition in the capillary tufts (endothelium) 
or in BoAvman's capsule (epithelium) but no 
permanent injury. Thus in the albuminurias 
associated with vascular hypertension or 
hypotension, the febrile and milder toxic al- 
buminurias we may have an explanation. 

Class C. — Nephrotic albuminurias, true renal al- 
buminurias where autopsy will later demon- 
strate actual lesion, but where this lesion is a 
nephrosis, or the retrograde and reparative 
changes consequent to the action of some 
poison either chemical or infectious. These 
albuminurias are likely to yield if the in- 
jurious focus of poison manufacture be re- 
moved or the poison be neutralized. 

Class D. — Nephritic albuminurias, true progres- 
sive renal albuminurias where autopsy will 
later demonstrate actual renal lesion, but 
where this lesion is a definite, classical neph- 
ritis rather than alterations consequent to the 
poisons from some distant focus. Either of 
the foregoing albuminurias may become a 
nephritis albuminuria. 

This volume cannot delve deeply into a considera- 
tion of the many forms of albuminuria. The signifi- 
cance of any albuminuria, let it be repeated, depends 
not so much upon its intensity as upon other clinical 
data, especially upon other urinary finds. Below is 
given an outline which may aid somewhat in diag- 



46 PRACTICAL tJRANALYSES 

nosticating a renal albuminuria, but it must be kept 
in mind that we are not always able to say whether 
or not the process is progressive even with bedside 
data : 

1. To prove a renal albuminuria, it is necessary 
that the albumin be serum albumin. 

2. Such an albuminuria must be persistent or 
nearly so. In vascular nephritis it may be intermit- 
tent and only frequent tests will show it. Diur- 
esis often explains why renal albuminurias may ap- 
parently cease, the clinical trace being rendered 
occult by dilution. 

3. If possible, other types of albuminuria should 
be ruled out. Inquiry should be made into the pos- 
sibility of euglobulinuria, Bence-Jones albuminuria, 
fever, hepatic and cardiac disease as well as tuber- 
culosis of the kidney and other local conditions. 

4. The serum albumin should be backed up by 
other urinary findings ; viz., casts especially cellular 
or granular types, urea paucity, renal cells, red 
blood cells, fatty granules, and protoplasmic debris. 

Serum Albumin, Detection. — Serum albumin oc- 
curs in the urine as a sol., or colloidal solution and 
there seems to be almost no limit to the quantity 
which may be present in a small amount of the 
urine. In one case examined by the author, a per- 
fectly transparent urine when heated became an 
amorphous mass from which but a few drops of 
water could be secured. 

The protein color reactions are not specific inas- 
much as other albumins or near-albumins may oc- 



CHEMICAL URANALYSES 47 

cur in urines. For the identification of serum al- 
bumin we have recourse to the coagulation tests, the 
resulting gel (incorrectly termed, precipitate) being 
visible to the eye as a cloudiness, coagulum or putty- 
like mass depending upon the amount of serum al- 
bumin present. 

A very large number of coagulation tests have 
been proposed, and it may be stated at the outset 
that there is no single ^^ all-round" test known. 
Three tests have been described below. The heat 
and nitric acid test should be used routinely and 
especially with those urines not easily cleared by 
filtration, where the question of Bence-Jones body, 
albumoses, urates, and phosphates enter, and in all 
urines which fail to show a cloudiness with other 
tests. Though usually regarded as a comparatively 
coarse method, it will often show serum albumin 
where the other tests fail. 

The other tests are recommended where it is de- 
sired to prove a trace of serum albumin. They can- 
not be applied to clouded urines, neither are they 
applicable when the possible presence of other pro- 
tein bodies pla^^s a part. The sulphosalicylic acid 
test is regarded as the most sensitive of all clinical 
methods. 

Heat and Nitric Acid Test. — Boil a specimen of 
the filtered urine. The sample should fill a test tube 
half full. If such cloudiness as has been present dis- 
appears, it has been due to amorphous sodium and 
potassium urates. If the urine is scarcely acid, a 
precipitate of earthy phosphates may occur which 



48 PRACTICAL URANALYSES 

will resemble very closely the cloudiness due to 
serum albumin, but which will be dissolved by add- 
ing acid. When the urine becomes hot but does not 
boil, observe it closely for evidences of cloudiness. 
(In alkaline urines serum albumin in small amounts 
may not be precipitated by heating, and for this 
reason it is often advisable to add just enough 
acetic acid at the beginning to neutralize the alka- 
lies.) When it is certain that the cloudiness cannot 
be cleared by moderate boiling (see Bence- Jones 
body, page 53), a couple of drops of pure nitric 
acid may be added. If the deposit does not dis- 
appear, we may be dealing with either serum al- 
bumin or euglobulin (the latter may account for the 
cloudiness as shown by the euglobulin test) or by 
adding an excess of the nitric acid the cloud will 
vanish. If but a few drops of the nitric acid clears 
the urine it is probable that the cloudiness was due 
to earthy phosphates, or, less likely, oxalates. An 
effervescence upon adding the acid, may be ex- 
plained by the evolution of carbonic acid gas and 
free nitrogen by the breaking up of the carbonates. 
In case the urine turns brown or mahogany in color 
we are dealing with the indicans, bile pigments, 
iodids or aromatic medicaments or other pigments. 
The sources of error Avill be considered below (see 
page 50). 

Nitric Acid Test. — This is often described as the 
cold test. The urine must be clear and Bence-Jones 
body be ruled out by other tests. This method has 
been very popular with clinicians and has been 



CHEMICAL URANALYSES 49 

variously modified but the principle is the same — 
floating a layer of the urine on a layer of the nitric 
acid. Heller's test is carried out by carefully pour- 
ing the urine down the side of a test tube previously 
filled up to 5 c.c. with the acid. Simon prefers a 
conical sedimentation glass for the test. Boston 
uses a glass pipet permitting the urine first to enter, 
and then sinking the pipet beneath the surface of 
the acid in such a manner as to secure a lower layer 
of this. A medicine dropper may be used in a simi- 
lar manner.^ The nitric acid must be pure and con- 
centrated, not fuming, as pigment reactions may in- 
terfere with the test. At the junction of the urine 
and the acid, a distinct white ring forms, and this 
is made up of the albumin coagulum. 

Sulpliosalicylic Acid Test, — Although the nitric 
acid test is regarded by many as the best method 
for detecting the trace of serum albumin, the author 
has used sulphosalicylic acid for this work with 
much better results. Though somewhat more costly 
it possesses the following advantages over nitric 
acid : 

1. Much safer to handle. 

2. May be kept for long period of time. After 
a certain length of time nitric acid begins to fume. 

3. More sensitive reagent for serum albumin. 
In the author's laboratory it is not uncommon to 
find serum albumin in many urines which fail to 
give a cloudiness with nitric acid. The sulpho- 
salicylic acid test is, however, an accepted clinical 



*Williams: lyaboratory Methods, page 111. 



50 PRACTICAL URANALYSES 

test and will not show the minutest traces of serum 
albumin regarded as physiological. The reaction is 
of especial value where casts and other evidences of 
disease are found, but where albumin is not demon- 
strated by other tests. 

The urine must be clear. It must contain no ap- 
preciable numbers of bacteria and no granules either 
of inorganic sediment or disintegrated cell proto- 
plasm, points easily determined by microscopy and 
other tests. A strong but not concentrated solution 
of the reagent in distilled water answers the pur- 
pose very nicely. A couple of drops of this solution 
are added to 5 c.c. of the transparent urine, and 
shaken sufficiently to mix. Do not heat. If after a 
couple of minutes, no cloudiness is noted, add two 
more drops. Compare with untreated sample of the 
urine as control. 

Serum Albumin, Sources of Error. — Most of these 
have been considered. It is best when deciding the 
questionable cases, to use the heat and nitric acid 
test. In case bacteria are present in large numbers 
and the urine cannot be clarified by filtration, the 
cloudiness cannot of course be cleared up by heat 
and nitric acid. Microscopy explains the trouble, 
but still in cases where it is desired to dem- 
onstrate the trace of serum albumin, there may be 
the opinion that such bacteria as are present can- 
not explain all of the cloudiness (contrast controls). 
Or if there is further question and it is impossible to 
secure a sample free from hosts of bacteria, shake 
up another specimen with calcined magnesia powder 



CHEMICAL URANALYSES 51 

and filter. Eeject the first portion of the filtrate 
and test the last portion. This will rid the nrine of 
most of the bacteria. Urines containing blood and 
pus will contain serum albumin, and tests cannot be 
set up with diagnostic profit even though the urine 
has been filtered, for only the cells remain on the pa- 
per and the albumin of the pus or blood as well as 
that derived from the kidney disease pass through. 
Whether blood or pus are actually present may be 
proved only by microscopy, and it is folly to con- 
clude that a positive albumin test means nephritis, 
if microscopy is neglected. If the number of blood 
or pus cells is small and large amounts of serum al- 
bumin are present in the urine, it is not reasonable 
to assume that all of the latter may be explained by 
the presence of the former. It may be very evident 
that some of the albumin is kidney albumin. 

If there is question in regard to the presence of 
Bence-Jones body, protract the boiling and do not 
add the nitric acid. In the case of possible eu- 
globulin, add an excess of the nitric acid or test 
another sample of the urine directly for euglobulin. 
Both serum albumin and euglobulin may occur in 
a specimen of urine, but this is rarely noted when 
pus and blood are absent. In such cases set up 
contrast tests alongside. 

Medicinal resins (copiaba, santal oil, etc.) do not 
precipitate readily during the heating but the cloud 
is formed when the acid is added. In questionable 
eases where euglobulin and earthy phosphates can 
be ruled out, it will not be necessary to add the acid, 



52 PRACTICAL URANALYSES 

but the boiling may be continued. Unless a history 
of medication is at hand the question may be a dif- 
ficult one to decide, if the urine is alkaline, for the 
necessary acidulation will favor either an albumin 
or resin cloud. Advice is sometimes given to permit 
cooling of the specimen and add alcohol to excess 
which will clear the liquid if the cloudiness be due 
to resins. But we have learned that perhaps some 
of the serum albumins may likewise disappear with 
such treatment. Briefly, therefore, a history of 
the medication is almost imperative. In case the 
physician sets up his own tests, he should not be 
misled. If he submits the sample to a laboratory 
man, he should supply this information. 

Finally it must be said that in exceptional in- 
stances, many other substances may simulate serum 
albumin — the bile acids, urea (as urea nitrate in 
concentrated urines), uric acid, gypsum, and per- 
haps others. In questionable cases it is well to turn 
to the suggestion of Winternitz. Eemove the ques- 
tionable coagulum or precipitate from the urine, 
and then thoroughly wash with hot, distilled water. 
When the filtrate ceases to give with silver nitrate 
a marked cloudiness, it is probable that all urine has 
been removed. Now pour upon this washed ma- 
terial in the filter, several drops of boiling Millon's 
reagent. A red color shows the protein nature of 
the material.'^ 



*This reaction is due to the aromatic nucleus of the protein mol- 
ecule. The urine must be entirely removed as similar reactions may 
be given by albumoses, tyrosin, indicaus, and so on. Millon's re- 
agent is made up by dissolving one part of mercury in one part by 
weight of concentrated nitric acid. The mixture is left cold for a 



CHEMICAL URANALYSES 53 

Bence-Jones Body. — This was once believed to be 
an albumose but it has been shown to be a trne al- 
bumin. It is almost pathognomonic of certain bone 
tumors especially of the myelogenic osteosarcomata. 
It has, however, been identified in the urine of 
leukemia and the author has found it in one case 
diagnosed as neurasthenia in which no organic dis- 
ease was discovered. The simple heat test is appli- 
cable for its detection. If the urine is alkaline, add 
a drop or two of acetic acid. Heat 5 or 10 c.c. in a 
test tube. As the urine becomes hot a coagulum 
rapidly forms but disappears when the boiling point 
is reached, finally to reappear when the contents 
of the tube are cooled under the tap. The reaction 
is characteristic and is not simulated by the other 
protein bodies, the latter when heated to 60° C, 
coagulating irreversibly or not at all. 

Globulins. — Serum globulin and related bodies 
are coagulated by all of the clinical tests for serum 
albumin. By special methods they may be differen- 
tiated from serum albumin, but inasmuch as they 
occur along with it and have no known diagnostic 
significance in themselves, space will not be given 
to the discrimination. 

Noncoagulable Urinary Proteins. — Peptones, al- 
bumoses and perhaps other bodies are included in 
this class. Urine from which the coagulable pro- 
teins have been removed by heat and filtration 



few hours and then gently heated until solution is complete. Then 
add two volumes of distilled water. Allow to stand from twelve to 
twenty-four hours and finally decant the clear liquid from any crystals 
which may have settled. 



54 PRACTICAL URANALYSES 

(making certain that the specimen is acid before at- 
tempting this procedure), may be tested by Millon's 
reagent. In the author's laboratory, Fittipaldi's 
test has given considerable satisfaction. To 5 c.c. 
of urine are added 30 c.c. of absolute alcohol. On 
the following day the liquid is decanted and the 
coagulum dissolved in a small quantity of soda. 
On treating this liquid with a freshly-made, am- 
moniacal solution of a nickel salt, an orange-red 
tint shows the presence of albumose. The clinical 
significance of the noncoagulable proteins is not al- 
ways clear. They may be found in severe infectious 
fevers and in cachexias. The finding of albumose in 
considerable quantity has been claimed to be pathog- 
nomonic of fetal death; and in questionable cases 
it has been advised that the urine of the mother 
should be tested. However this contention has not 
been conclusively proved. 

Many other protein bodies have been reported as 
being found in specimens of urine; but the diag- 
nostic meaning of these has not been made clear. 
Amino acids have been found in normal urines. In 
acute yellow atrophy of the liver, this organ fails 
to convert the excess of amino acids into urea and 
they may be found in the urine (see leucin and ty- 
rosin, page 113). 

Hemoglobin and Related Bodies. — Two types of 
hemoglobinuria must be distinguished ; viz. : 

1. True Hemoglohiniiria. — This occurs in con- 
nection with hemoglobinemia (release of hemo- 
globin from erythrocytes in the blood stream). 



CHEMICAL URANALYSES 55 

Hemoglobinemia sufficient to result in hemoglobin- 
uria, is caused by certain poisons (chloroform, 
chlorates, crotalin, carbolic acid) called hemolytic 
bodies. Even quinin and the coal-tar antipyretics 
may lead to hemoglobinemia and consequent hemo- 
globinuria if administered in large doses. Upon the 
other hand hemoglobinemia may be observed with- 
out hemoglobinuria as in chlorosis where there is 
rapid loss of hemoglobin, we may not be able to 
demonstrate it in the urine of the patient. In true 
hemoglobinuria few or no red blood cells are found 
in the urine. 

2. Hematuria, or Incidental Hemoglobinuria. — 
Hemorrhage may occur at some point in the urinary 
tract, as in the painful oxalurias, renal calculus, the 
classical nephritides, renal phthisis, renal cancer, 
almost all of the organic diseases of the bladder and 
prostate and even from the urethra. By microscopy 
the erythrocytes may be identified, though sometimes 
with difficulty if the hemorrhage occurs high in the 
urinary tract or if there is retention in which case 
crenated cells and blood shadows may take their 
place. But by careful work, true hemoglobinuria 
and hematuria may usually be distinguished. The 
two conditions may of course coexist but the study 
of many urinary specimens shows that they do not 
as a rule occur at the same time. 

Hemoglobin and its derivatives cannot be con- 
sidered normal urinary pigments. The finding of 
these bodies by chemical tests, proves organic dis- 
ease, but the finding of red blood cells is almost nee- 



56 PRACTICAL URANALYSES 

essary before we can prove that this blood was re- 
leased in the urinary tract. Furthermore the phy- 
sician must be on the lookout for possible contamina- 
tion from the genitals, especially in menstruation; 
-and in questionable cases catheterization may be 
imperative for the distinction. 

Known that the blood comes from the urinary 
tract, it often becomes very necessary to determine 
the exact point of the bleeding. Much appears in 
medical literature upon this subject, but it is not 
always an easy matter. The modern cystoscopic 
work promises more than do either bedside or lab- 
oratory examinations. This being a laboratory book, 
a few points will be considered as regards the loca- 
tion of the lesion by the uranalysis. 

1. Kidney blood is likely to show more crenated 
forms and ghosts than where the hemorrhage oc- 
curs lower down. Other renal findings as casts 
(especially blood casts), renal cells and so on may 
give the clew. The coexistence of an acid pus is 
likewise suggestive. 

2. Ureteral blood may be accompanied by ure- 
teral cells and in some cases by large numbers of 
minute acicular crystals of lime oxalate. 

3. Bladder blood is not flaky as a rule unless 
retention renders it so, and retention may always 
be proved clinically. When alkaline pus coexists, 
it points to bladder origin for both pus and blood. 
Vesical cells have a similar significance. 

Detection of Hemog'lobin and Derivatives. — Three 
excellent tests are given below. The first of these 



CHEMICAL URANALYSES 57 

is practically specific for blood pigments. The other 
two are by no means specific being given by an al- 
most endless list of other substances, but are de- 
tailed because they are extremely sensitive and 
when absent, rule out all possibility of the presence 
of hemoglobin. 

Heller's Test. — Strongly alkalinize 10 c.c. of the 
urine with sodium hydroxid. Heat to boiling but do 
not boil. A precipitate may be explained by the 
earthy phosphates and other salts. If however this 
precipitate is colored red, we know that hematin, a 
hemoglobin decomposition product, is present. This 
is not a very sensitive test as contrasted with those 
to follow, but is practically specific. 

Van Deen's Test. — Keep in mind the interpreta- 
tion noted above. Mix thoroughly 5 c.c. of urine 
and 5 c.c. of a freshly made tincture of guaiac 
(made by dissolving a piece of gum guaiac in abso- 
lute ethyl alcohol). The mixture will become milky 
in appearance. Add 2 to 5 drops of pure peroxid 
of hydrogen and shake once more. Set aside the 
tube. At once or within a short time a blue or 
green tint will be noted which may be counted a 
positive test. Alkaline samples must be acidified 
with acetic acid before applying this test. 

Aloin Test. — Keep in mind the interpretation 
noted above. To 5 c.c. of the urine, add 1 c.c. of 
glacial acetic acid. After 30 minutes add 3 c.c. of 
ether and cork to prevent evaporation. After 30 
minutes, pour off this ether into a small test tube 



58 PRACTICAL URANALYSES 

or a clean vial and add a grain of powdered aloin. 
Finally add an equal volume of pure peroxide of 
hydrogen. A positive test is shown by a cherry-red 
color. 

Bilirubin and Related Bodies.'^ — Even as hemo- 
globinuria may be noted in hemoglobinemia, so may 
bilirubinuria accompany bilirubinemia (by biliru- 
binemia in this connection is meant the presence of 
bilirubin in the blood and tissues). We cannot 
enter into the various causes of bilirubinemia and 
cannot consider in this volume the clinical manifes- 
tations of the condition, but must give our attention 
chiefly to the chemical derivation of bilirubin and 
why it is found in pathological urines. Waste hemo- 
globin is excreted by the liver cells, and passes 
from the liver capillaries normally as bilirubin 
(hemoglobin minus iron and globulin); and bil- 
irubin is a poisonous substance. Normally this bil- 
irubin and its secondary products pass into the in- 
testine, are further altered into less poisonous 
bodies, and escape from the body by the bowel and 
urine. 

But in certain patliological processes, it is not 
completely excreted by the biliary capillaries, but 
passes back in part unaltered into the general cir- 
culation to be eventually deposited in the tissues 
or excreted — mainly by the kidney. Once a part of 
the hemoglobin molecule and favored in chemical, 
physiologic processes, bilirubin has been robbed of 



*Williams, B. G. R., **Bilirubinuria," Illinois Medical Journal, 
February, 1912. 



CHEMICAL URANALYSES 59 

its iron and cast aside as a waste substance. Enter- 
ing again into its former domicile, it is made rid 
of by the circulation as rapidly as possible and at 
any cost. Possibly it is neutralized in part, but that 
which is not thus disposed of destroys many cells. 
Among these cells, the following type bear the chief 
injury. 

1. Hepatic cells, leading often to urobilinogen- 
uria or decreased urea elaboration. 

2. Erythrocytes, leading to erythrocytolysis and 
even hemoglobinuria. 

3. Blood platelets or other cells and substances 
concerned in blood clotting. In bilirubinemia, the 
coagulation time of the blood may be greatly 
lengthened. 

4. Eenal cells, toxic desquamation into urinifer- 
ous tubules. Eenal cells and albumin often accom- 
pany bilirubin in the urine. 

Bilirubinuria, even though slight, must be re- 
garded as a pathological condition. 

Tests for Bilirubin and Related Bodies.— Though 
arising from hemoglobin, these bodies cannot be 
identified by those methods which we use for hemo- 
globin and its other derivatives. 

In marked bilirubinuria, the urine may be golden, 
but there are other golden urines, and chemical 
tests should always be applied. The presence of 
yellow or green tinted casts in a specimen should 
always lead us to test for bilirubin. 

Foam Tests. — Shake very thoroughly a sample of 
the urine. A greenish, yellowish or brownish tinge 



60 PRACTICAL URANALYSES 

shows that bilirubin must be present. No known 
urinary pigment will so color the foam though of 
course extraneous substances introduced into the 
sample might do so. This test may be confirmed 
by the chemical reactions. 

Filter Paper Test. — To a large quantity of the 
urine (acidified if alkaline) add aqueous solution of 
barium chlorid, drop by drop until no more pre- 
cipitate appears. Mix well the contents of the tube, 
and filter several times through a thick filter paper. 
The bilirubin is held on the paper with the sulphates 
and phosphates. Meanwhile to 5 c.c. of concen- 
trated nitric acid in a test tube, add a bit of clean 
wood (tooth pick or match stick) and heat carefully 
until yellow fumes are given off. Then cool under 
the tap. When quite cool, this reagent will be ready 
for use. 

After filtration has been repeated and complete, 
remove and unfold the filter paper. Dry off excess 
liquid with another filter paper very carefully so 
as not to disturb the precipitate. Permit a drop of 
the cool, yellow acid to fall upon the paper. In 
the presence of bilirubin, a green band forms at 
its edge. Rapidly this band journeys outward and 
is followed by other color rings — blue, indigo, pur- 
ple, red and yellow, but the green ring is always 
external and is the specific ring for bilirubin, as in- 
dican, iodids and other substances may give rise to 
the others. This test is doubtless much more spe- 
cific than the foam test, but not always so sensitive, 
as very small amounts of bilirubin may be appre- 



CHEMICAL URANALYSES 61 

ciated with the foam test by the experienced ob- 
server. 

Hammer stein-Nakayama Test. — This is a very 
sensitive test for bilirubin. Equal parts of an acid 
or acidulated urine and ten per cent barium chlorid 
solution in distilled water are mixed and well 
shaken. Ten cubic centimeters of this mixture are 
placed in a centrifuge and centrifugalized until the 
supernatant liquid is clear. Reject the liquid and 
keep the sediment for the testing. Now quickly 
make up the Hammerstein reagent as follows : 

Acid nitric, 25% 1 drop. 

Acid hydrochloric, 15% 19 drops. 

Alcohol, 75% 5 c.c. 

About one-third of this reagent is quickly added 
to the precipitate in the centrifuge tube and the 
contents shaken thoroughly. Centrifugalize. A 
green tint in the supernatant liquid indicates the 
presence of bilirubin. 

lodin Test, — A few drops of tincture of iodin are 
superimposed upon 10 c.c. of the urine. A green 
contact ring appearing Avithin a minute is due to 
bilirubin. A greenish ring appearing later is not 
regarded as a positive test. 

Bile Acids. — Until the past few years the bile 
acids or their salts Avere supposed to be the toxic 
and otherwise important causes of those morbid 
symptoms coincident with the entrance of the 
hepatic excretory products into the blood. Their 
detection has always been a difficult matter. It is 



62 PRACTICAL URANALYSES 

with considerable relief, therefore, to the diagnosti- 
cian that these older views have been proved incor- 
rect and his attention directed to bilirubin. For 
this reason, a consideration of the bile acids has 
been omitted and the reader is referred for par- 
ticular information to books upon physiological 
chemistry. 

Urobilinogen, Its Significance. — The urobilinogen 
reaction may be regarded as a functional liver test. 
Normal liver cells do not permit the escape of 
urobilinogen of appreciable quantity into the gen- 
eral circulation and into the urine. A very slight 
injury of the liver may be followed by the presence 
of urobilinogen in the urine. It seems that unin- 
jured cells of the liver are able to compensate in 
part for those which have been distroyed or weak- 
ened. Thus urobilinogenuria may be present in a 
mild condition w^here most of the liver cells are in- 
volved; for example, passive congestion, angiocho- 
litis, cirrhosis, hepatic syphilis and so on ; it may not 
be found in certain of the local severe diseases of 
the liver, as abscess, cancer, or trauma. The dis- 
ease need not be primary in the liver for urobilino- 
genuria to occur. The condition may be secondary 
by virtue of poisons, anemia, congestion, and so on, 
leading to stupefaction of the parenchyma. It is 
commonly noted in the venous congestion of valvu- 
lar lesions, in arterial disease, in pernicious anemia, 
typhoid, and scarlet fever. The test is a very sensi- 
tive one, and is not a measure of the severity of the 
lesion. Urobilinogenuria occurs early in all condi- 



CHEMICAL URANALYSES 63 

tions resulting in stupefaction and sluggish func- 
tionation of the liver cells; amino acids appear in 
the urine when the cells are undergoing actual de- 
struction. 

Urobilinogen, Its Detection. — The urobilinogen 
reagent of Ehrlich and Neubauer, is prepared as fol- 
lows : Dissolve one gram of paradimethylaminoben- 
zaldehyd in 10 c.c. of pure hydrochloric acid. Then 
add 5 drops of alcohol and distilled water up to 50 
c.c. total quantity. This may be kept for a consid- 
erable period of time. 

To 5 c.c. of the filtered urine add a couple of 
drops of the reagent and shake gently. Do not heat 
but set aside at room temperature. After a minute 
or so the presence of urobilinogen will be shown by 
the appearance of a beautiful cherry red color. The 
reaction may be delayed an hour or so in some cases 
but usually appears in five minutes. A yellow or 
pinkish tint (observed by holding the tube in direct 
sunlight) must be regarded as a negative reaction. 

Uric Acid, Its Detection. — Uric acid appears in 
the urine as such or as its salts. It may be found 
in normal urine, but when present in considerable 
amount must be regarded as pathological or semi- 
pathological (may be greatly increased by a heavy 
proteid diet). It is well to be able to identify it as 
a constituent of calculi, and so the following test is 
given : To some of the material, add an equal quan- 
tity of nitric acid and evaporate in a porcelain dish 
on a water bath until quite dry. A yellowish res- 
idue remains. Remove the dish from the bath and 



64 PRACTICAL tJRANALYSES 

permit it to cool. When quite cold, expose to am- 
monia fumes. The residue becomes reddish-purple 
if the material is uric acid. 

Glucose, Its Significance. — Traces of glucose may 
be identified by special methods in practically any 
specimen of urine. Such a glucosuria is termed 
physiological. Considerable amounts of glucose 
may appear in the urine but be transient and the 
case is not one of true diabetes. To this condition 
is given the term, alimentary glucosuria. The nor- 
mal limit of sugar assimilation varies not only in 
different persons but at different dates in the same 
person. To prove diabetic glucosuria, it is neces- 
sary to prove that glucose is persistent or almost so 
even when carbohydrates are somewhat restricted. 
In soma atypical cases of true diabetes, glucose may 
be present in the urine for a few days or weeks, dis- 
appear when the diet receives but slight attention 
only to reappear with the slightest excuse. Some of 
these baffling cases may be affected with diabetes 
for many years, be complicated with diabetic gan- 
grene or even symptoms of acidosis, reach an age of 
60 or 70 years and then die of some other malady. 
The author has observed several of these baffling 
cases. 

Of the many theories of diabetic glucosuria, two 
have gained a prominent place in the literature. 
That of Chauveau and von Noorden claims the trou- 
ble to be sugar overproduction in the body ; but the 
more plausible and acceptable one refers the diffi- 
culty to imperfect utilization of the carbohydrates 



CHEMICAL URANALYSES 65 

by the tissues. At any rate, hyperglycemia, or 
sugar-saturation of the blood occurs. Glucose is an 
excellent diuretic and is excreted mainly or entirely 
by the kidneys. The intensity of the polyuria varies 
directly with the amount of glucose excreted by the 
kidney. 

More rarely other forms of glucosuria may be met 
by the physician. Thus in injuries to the medulla, 
the output of glucose may be great, and such cases 
present a very unfavorable prognosis as a rule. The 
phloridizin glucosurias are explained as a rule by 
the splitting of this substance into sugar and 
phloretin. Eenal glucosurias are characterized by 
the fact that hyperglycemia does not occur. Klem- 
perer has ventured the explanation that the renal 
epithelium becomes morbidly active excreting the 
physiological sugar of the blood very rapidly, and 
continues to do so as the deficiency is replaced. 

An antagonistic relation between the pancreas 
and adrenal glands has been supposed to exist with 
reference to the determination of the glucose con- 
tent of the blood. It is scarcely necessary to re- 
hearse the well-known fact that extirpation or dis- 
ease of the pancreatic gland results in glucosuria, 
and that many if not all cases of diabetes are pan- 
creatic in type. Moreover the injection of sub- 
stances from the adrenal may cause glucosuria. It 
has been argued, therefore, that one organ acts 
physiologically as a check upon the other, and that 
pathological glucosuria which cannot be attributed 
to pancreatic disease may be explained by hyper- 



66 PRACTICAL URANALYSES 

activity of the adrenals. This theory is interesting 
but lacks final proof. However a striking feature in 
at least two of the atypical cases of diabetes men- 
tioned above, is that both patients suffer from hy- 
pertension and albuminuria. 

To repeat, the pathological glucosurias most fre- 
quently met by the practitioner (and which have 
come to fall under the general heading, diabetes 
mellitus) must be considered, according to the con- 
sensus of opinion, as anabolic shortcomings on the 
Ijart of the tissue cells toward glucose. In other 
words, for reasons which we do not clearly under- 
stand, the body cells are unable to use the sugar 
brought to them, and it must pass by them and be 
excreted while they suffer sugar-starvation. 
Whether these anabolic shortcomings are due to the 
absence of some specific ferment formerly supplied 
by the pancreas or other organ, or due to nervous 
influences, or both, we are not yet ready to declare. 

Glucose, Its Detection. — No one test is without its 
shortcomings and so several will be described. 

Spoon Test. — This is most easily applied at the 
bedside. Dilute some of the urine with double its 
volume of water. Place about six drops in a spoon 
and slowly evaporate to dryness with gentle heat. 
Then heat again very slowly, when all at once a 
typical orange-brown color and a characteristic 
odor of caramel will prove the presence of glucose. 
Other urines give a smoky black spot and merely 
a urinous odor. This test is fairly sensitive. It may 
serve very well when reagents are not at hand (sud- 



CHEMICAL URANALYSES 67 

den coma suspected to be diabetic in origin) ; but it 
is Avell to apply other tests later. 

Haines Test. — The Haines test appears to have 
replaced the Trommer and Fehling tests with the 
majority of laboratory workers, not only because of 
its simplicity but because it is satisfactory as well. 
T[: must be remembered that the reagent and not. the 
urine is to be boiled. The reagent need not be made 
up fresh for each test but should be discarded if 
any precipitate appears in the bottle or should be 
thrown down in the boiling. It is made up as fol- 
lows, and attempts to shorten the method of prepa- 
ration are likely to lead to trouble : IMake a perfect 
solution of 30 grains of pure copper sulphate in one- 
half ounce of distilled water. Mix thoroughly Avith 
a half-ounce of glycerin. Finally add 5 ounces of 
clear liquor potassae. The reagent is fairly stable 
and may be kept in a rubber stoppered bottle almost 
indefinitely. 

Boil 5 c.c. of this reagent in a test tube. Hold in 
the light to see that no reduction has occurred. 
Quickly add 5 to 7 drops of the filtered urine, not 
more. Keep the reagent at the boiling point until 
the moment of adding the urine, and then remove 
from the flame. A copious and lieavy yellow, green 
or brown, sand-like precipitate indicates the pres- 
ence of glucose. A slight, flaky- white or dirty col- 
lection of crystals or flocculent material indicates 
either a partial reduction of the reagent, albumin- 
ous bodies, or phosphates. A delayed action (ap- 
pearing a minute or so later) is probably due not to 



68 PRACTICAL URANALYSES 

glucose but other reducing substances. The charac- 
teristic reaction once seen is rarely mistaken for a 
pseudotest. It is the latter which is taken for the 
glucose trace by the unskilled observer. 

Fermentation Test. — The Haines test is almost 
specific for glucose. Clinically in the hands of a 
man who has applied it many times, it is quite spe- 
cific. From a strictly scientific standpoint the fer- 
mentation test is always specific. In the fermenta- 
tion test the glucose is broken up into alcohol and 
carbon dioxid, the evolution of gas being proof of 
the alteration. Other reducing bodies which might 
be confused with glucose, will not ferment. The 
test may be set up in an ordinary bottle or in a spe- 
cial saccharimeter such as will be described in con- 
nection with the quantitative ur analyses (see page 
101). 

The urine should be kept warm during the test, 
preferably by an incubator, and must be free from 
preservatives. Any commercial yeast which is glu- 
cose-free may be used, but the compressed yeasts 
are best of all. The only objection to the test is 
that some time is required for fermentation to take 
place, but this is not a great objection inasmuch as 
chronic rather than acute cases demand this work. 
A very small amount of yeast is sufficient but it 
should be well mixed with the urine sample by 
shaking. 

Cole Test. — The Cole test for glucose is perhaps 
the most sensitive of all the clinical glucose meth- 
ods; and in the question of traces, is considered by 



CHEMICAL URANALYSES 69 

the author as our best rapid method, even more sen- 
sitive than the fermentation test. In fact Cole* 
claims that in devising the perfected technic, the 
greatest difficulty lay in the fact that it was likely 
to show the presence of normal amounts of glucose. 
In a dry, large test-tube, place about one gram of 
pure blood charcoal. Add 10 c.c. of the urine and 
shake from side to side to mix thoroughly. Heat to 
the boiling point, shaking the whole time. Cool 
thoroughly under the tap and shake thoroughly for 
about five minutes. Filter through a small paper 
into a rather wide test tube containing about half 
a gram of anhydrous sodium carbonate. When the 
liquid has filtered through, add 6 drops of pure 
glycerin, shake and heat to boiling. Note the time 
when boiling commences and maintain active boil- 
ing for 50 seconds, shaking from side to side to pre- 
vent spurting. Immediately add four drops of a 
five per cent solution of crystallized copper sul- 
phate. Shake for a moment to mix the solutions, 
and allow the tube to stand without further heating 
for one minute. With normal urine, the color re- 
mains blue, with a variable amount of a grayish 
precipitate of the earthy phosphates. 

If glucose is present to the extent of .02 per cent 
or more above the average normal amount, the blue 
color is discharged and a yellowish precipitate of 
cuprous hydroxid forms. The rapidity with which 
the precipitate forms is a measure of the amount of 
glucose present. With .05 per cent, it appears in a 



*Iyancet, Ivondon, September 20, 1913. 



70 PRACTICAL URANALYSES 

few seconds. With .02 per cent it may not appear 
until 50 seconds. A reaction taking place after 60 
seconds must not be taken as evidence of abnormal 
glucosuria. 

The chief principles involved in this test, are : 

1. Charcoal in a certain percentage absorbs the 
greater part of the nonsaccharine reducing sub- 
stances of normal urine, the greater part of any lac- 
tose which may be present, and so on. 

2. Cole claims that certain advantages may be 
realized by this special mixing of carbonate, 
glycerin, and copper. This is doubted by the author 
of this book, who sees in it merely an unnecessary 
modification of Haines method well knoAvn to all 
American laboratory men. The method may well 
be termed the Cole modification of Haines test. It 
may be Avell in puzzling Haines reactions to treat 
the urine with charcoal as advised above, cool it and 
then filter, using the filtrate with the boiling Haines 
reagent. This appears to be as satisfactory as the 
methods described by Cole. 

Glucose, Sources of Error.— The Haines reagent 
must be transparent and must not reduce itself 
when boiled. Excessive amounts of urine must not 
be added — the limit for 5 c.c. of reagent is seven 
drops of urine. Do not boil after mixing. The dirty 
flocculent sediment Avhich sometimes may be ob- 
served is a precipitate of earthy phosphates, or pos- 
sibly albumin if this has not been removed. The 
glucose sediment should not only be heavy, or sand- 
like, but is usually copious. Moreover it should ap-. 



CHEMICAL URAXALYSES 71 

pear rather promptly. A partial reduction appear- 
ing after a couple of minutes is likely to prove to 
be other sugars or nonsaccharine reducing sub- 
stances. Specimens of urine submitted in triturate 
vials (lactose), maple syrup containers and patent 
medicine bottles should be examined A^dth consid- 
erable caution. It is Avell to repeat that the pseudo- 
test is more often mistaken for a trace of glucose 
than is a typical glucose reaction for a pseudotest. 
Here as in many other questions, laboratory men 
will find that ^^ practice makes perfect.'' The man 
Avho is uncertain of his technic should work with 
controls containing known percentages of glucose. 
_ Uric acid, salicylic acid, hydroquinone, para- 
eatechin, and other substances may cause a reduc- 
tion especially if the technic is not carefully carried 
out. However it will be found that the reaction is 
usually delayed or incomplete. In this connection it 
is well to keep in mind that dependence is to be 
placed more upon characteristic precipitation 
rather than change of color of the reagent. But in 
case of further question and especially if the specific 
gravity is not elevated, it is well to resort to the 
fermentation test or to the Cole test. A trace of 
serum albumin will not seriously interfere with the 
Haines test. A large amount of albumin may con- 
fuse. In such case, add a drop of acetic acid to 10 
c.c. of the urine in case it is alkaline, boil and filter 
through a clean paper. Use the filtrate as unknown. 
When setting up the fermentation test, the speci- 
men must contain no preservative as the action of 



72 PRACTICAL URANALYSES 

the yeast will be inhibited. The reaction will not 
occur in a cold room, and is most rapid at 25° C. 
Some commercial yeasts act very slowly, and some 
are inert. Brewer's yeast or the ordinary com- 
pressed yeast kept on ice, is best for use. If the 
urine appears to contain bubbles of air or other gas, 
it is best first of all to boil and then permit to cool 
before setting up the test. 

Pentoses, Significance and Detection. — The pen- 
toses (arabinose, xylose, rhamnose, and so on) occur 
in fruits and vegetables. Urinary pentose is usually 
an optically inactive arabinose. It has been found 
in diseases of the pancreas in company with dex- 
trose, but sometimes alone. Cases of essential or 
crytogenic pentosuria -have been met with, where 
there is no dextrose, no polyuria, no thirst and often 
no symptoms. The specific gravity of the urine is 
usually above 1030 and a positive reaction with the 
reduction tests often leads to a diagnosis of true dia- 
betes (glucosuria). HoAvever, the sugar is not 
broken up by yeast fermentation, and this should 
place the physician on his guard. 

Pentose may be identified positively by Bial's 
test. One-half gram of orcin in 500 c.c. of 30 per 
cent hydrochloric acid, and 20 drops of liquor ferri 
sesquichloridi are added. This will serve as reagent 
and is stable for several months. About 5 c.c. or 
somewhat less of the reagent are heated in a test 
tube until the boiling point is reached. Do not,, 
however, permit it to boil. As soon as the tube is 
removed from the flame, 10 drops of the urine are 



CHEMICAL URANALYSES 73 

added. Within a few seconds, the liquid turns 
green if pentose is present. A green tint occurring 
a minute or so later may be due to glycuronic acid. 
If glucose is present, it will give the orcin test and 
should first be removed by fermentation. In highly 
colored urines (concentrated urines where normal 
reducing substances are increased per c.c), animal 
charcoal should first be added, and after heating, 
the mixture may be filtered and the clear filtrate 
may be tested. However, it is well to remember that 
pentoses occur in some filter papers and may be dis- 
solved out especially if the urine is highly acid. In 
ease of question, run controls alongside. 

Where glucose is not present and it appears that 
we are dealing with a single sugar, positive identi- 
fication may ofttimes be made by Neumann's mod- 
ification of the orcin test. It is necessary here for 
the safety of the worker that a wide test tube be 
used and that the mouth be directed away as the re- 
action is sometimes attended by explosive violence. 
Five or seven drops (not more) of the urine are 
placed in the tube and then are added 5 c.c. of gla- 
cial acetic acid and 5 drops of a 5 per cent alcoholic 
solution of the orcin. Finally we heat the mixture 
to a boil. Then add sulphuric acid carefully, drop 
by drop, holding the mouth of the tube away from 
the face to guard against explosion. After adding 
each five drops, shake the tube. When a first per- 
manent color is secured, add no more acid. It may 
be necessary to add quite a little acid but never 
more than 50 drops are necessary. Do not boil the 



74 PRACTICAL URANALYSES 

mixture at any time. When the temperature has 
reached the boiling point, remove from flame and 
then add the acid. Finally cool. By this method it 
is easy to discriminate between the sugars, if but 
one is present. The pentoses give violet hues; glu- 
cose, broAvn, and glycuronic acid, green. The latter 
substance though an aldehyde is closely related to 
the sugars and is responsible for many of the 
pseudotests for them. 

Lactose, Significance and Detection.— At some 
points in lactation, tests of the mother's urine are 
quite likely to show the presence of sugars. The 
reaction to Haines test may be delayed but is pos- 
itive for lactose. Lactose is most likely to be found 
in the urine of the mother when the breasts are dis- 
tended with milk. Distinction rests not alone upon 
the clinical circumstances but upon the fermenta- 
tion test which breaks up glucose but does not af- 
fect lactose. 

Diacetic Acid, Significance. — The acetone bodies 
('acetone, diacetic acid, beta-oxybutyric acid, and 
other substances) play an important if not the chief 
part in the acidoses of diabetes as well as in other 
toxemias as yet not perfectly understood. When 
all evidence is in, we are not certain as to the iden- 
tity of the acetone precursors. It is fairly evident 
that they do not arise from the sugars but repre- 
sent an attempt either upon the part of the proteids 
or the fats to split into products of two types, one 
the needed carbohydrate for the cell, the other the 
waste products resulting from such cleavage. At 



CHEMICAL. URANALYSES 75 

any rate it is probable that the acetones are indica- 
tive of ^^carbohydrate starvation" where as in dia- 
betes, the tissues are unable to use the carbo- 
hydrates brought to them and past them, or where 
as in postanesthetic vomiting, appendicitis, preg- 
nancy and so on, the tissues are clamorous for sugars 
but either these have not been supplied (diet before 
anesthetic usually is meager), or if supplied have 
not been assimilated by the portal circulation (ap- 
pendicitis). In consequence, proteids or fats are 
broken up to gain their carbohydrate portion, and 
poisonous remnants are left. 

Coincident to the appearance of acidosis, falls the 
urea. This must not be mistaken for retention but 
rather as failure of elaboration. For when the acids 
and acid-like bodies are freed into the blood and 
lymph, the ammonia combines in part to neutralize 
them, that the fixed alkalies of the tissues may be 
spared. The ultimate antecedent or at least the 
representative of such is supposed to be beta- 
amidobutyric acid ; but it has not been identified in 
the urine. 

Diacetic Acid (Aceto-acetic Acid), Detection. — 
Eoutiiiely we rarely test for other of this series than 
diacetic acid. These bodies are very volatile so that 
tests should be made as soon as possible. In the 
Gerhardt's test the urine must be added to reagent, 
instead of reagent to urine as is usually advised. 

Gerliardt's Test. — ^To about 10 c.c. of a clear, 
strong solution of ferric chlorid, add 2-3 drops of 
the urine. A wine-red color indicates the presence 



76 PRACTICAL URANALYSES 

of diacetic acid. A deep red, purple, or bro^vn color 
indicates the presence of salicylates, coal-tar prod- 
ucts and so on. This is best demonstrated by the 
fact that a control set up with some of the urine 
which has been boiled will show a color quite as 
intense whereas if it were diacetic acid, this being 
volatile, no or but little color would appear. As a 
matter of fact these drugs should not be exhibited 
before the test is set up, as they will obscure the 
true diacetic acid tint and the examiner be left in 
question. 

Lindemann's Test, — Shake together 10 c.c. of the 
urine, 5 drops of acetic acid, 5 drops of Lugol's 
iodin solution (or double amount of this solution if 
urine is charged with uric acid), and 3 c.c. of chlo- 
roform. "With urine containing diacetic acid, the 
chloroform is not colored. With other urines a pink 
or red chloroform results from the escape of un- 
bound iodin. This specific binding is accomplished 
by diacetic acid. 

Acetone, Detection. — We have considered above 
the meaning of acetone in the urine. We usually 
test for diacetic acid and in case of further question 
seek to detect acetone. This occurs in merest traces 
in the normal urine, but is not shown by the Trom- 
mer test unless it occurs in abnormal amounts. It 
may be present either in the urine or the breath in 
amounts sufficient to be detected by its odor. It has 
been ventured that more acetone leaves the body by 
the expired air than by the urine. This odor has 
been variously described. It approaches that of ap- 



CHEMICAL URANALYSES 77 

pies just beginning to rot. It is characteristic and 
once perceived is rarely mistaken in the future. 

Trommer Test. — The Trommer test has become 
very popular in many laboratories ; and for routine 
purposes is much to be preferred to the older meth- 
ods. It is a very sensitive test. Add a gram of dry 
potassium hydroxid to 10 c.c. of the urine; and to 
this alkalinized urine in turn add 10-15 drops of 
salicylic aldehyde. Warm the mixture in a flame 
but do not raise to boiling (rather to the tempera- 
ture that it just burns the palm of the hand). A 
red or purple ring at the line of contact proves that 
acetone is present. 

The Indicans, Significance. — So nearly as we are 
able to judge, indicanuria invariably signifies the 
occurrence of proteid decomposition at some point 
in the body. Certain authorities have ventured to 
gainsay this conclusion, possibly because the focus 
of putrefaction is not always evident. However, the 
recent studies of the etiology of toxic (infectious) 
arthritis and certain forms of nephritis, show that 
hidden and symptomless infections are fairly com- 
mon. It follows that many of these indicanurias 
which cannot be traced to the bowel may be thus 
explained. However, in the great majority of cases 
morbid biological processes in the colon must be 
held to account. 

Indicanuria is not to be regarded as an index to 
simple constipation. It may result from proteid 
gluttony (the American dietetic sin). It may result 
from incomplete digestion, absorption and assimila- 



78 PRACTICAL URANALYSES 

tion of the proteids higher in the alimentary tract. 
(After all, there is but one bowel; and anatomical 
divisions are sometimes misleading.) In enter- 
optosis the formation and absorption of indicans is 
enhanced. 

What occurs is this. Because of colonic stasis, or 
for other reasons, certain bacteria act upon the 
food-proteids, breaking them up into a large num- 
ber of more or less poisonous bodies. The bowel 
serves merely as the incubator. These bodies are 
taken up in part by the blood and eventually reach 
the kidney. The symptomatology has been debated, 
but symptoms undoubtedly oyccur and are variable. 
However, they are w^ell known to most physicians 
and need not to be detailed here. A hairsplitting 
debate has rendered the term, autointoxication un- 
desirable. We now speak of the condition as intes- 
tinal toxemia (copremia), another term which has 
been criticized, but which will answer well enough 
until these critics have devised a better one. 

We have spoken of the role of the acids (see page 
38). Indican proper is the product resulting from 
the oxidation of indol and its subsequent conjuga- 
tion with simple sulphates. 

The Indicans, Detection. — Mix in a test tube, 5 
c.c. each of urine and hydrochloric acid. Add about 
2 c.c. of chloroform and a couple of drops of reliable 
peroxid of hydrogen. Place the thumb over the 
open end of the tube and gently shake or invert 
several times. If a reaction fails, shake again or 
add a few drops of alcohol and shake. 



CHEMICAL URANALYSES 79 

The ordinary indican is blue indican. If it is 
present in traces it will impart to the chloroform a 
delicate sky-blue color. In larger amounts the chlo- 
roform will become as dark blue as a five-cent post- 
age stamp. Excessive quantities of indican give a 
violet hue while in severe tuberculous enteritis, 
strangulation and so on, the chloroform may be 
quite black. Usually the entire contents of the tube 
may show some color although most of it is concen- 
trated in the chloroform. 

Indigo red or urorosein gives a pink or red color 
to the chloroform in exceptional substances. Any 
urorosein which may be present is usually obscured 
by the blue indican. Urorosein is supposed to be a 
skatol derivative. 

The Indicans, Sources of Error. — In routine labo- 
ratory work the chief pseudotest may be explained 
by the iodids. The chloroform becomes pink, and 
the color is quickly discharged by setting in direct 
sunlight or by reshaking after the addition of alco- 
hol. Urorosein should always be reported with re- 
luctance. It is rarely found and inquiry will usu- 
ally reveal the fact that the patient is taking iodids. 
Moreover proof may be had by Lesser 's test. He 
stirs with the end of a match stick a little calomel 
into a few drops of the urine on a slide. If it con- 
tains iodin, the calomel becomes bright yellow. In 
case of further question run a control alongside 
with normal urine. In all cases of importance, do 
not administer salicylates, urotropin and iodids be- 
fore testing for indican. 



80 PRACTICAL URANALYSES 

Bilirubin may give a pseudotest, but it may be 
identified by other tests and the error shown. 
When chloroform has been added to a sample to pre- 
serve it until it can be examined, it is well to test 
this for indican as the chloroform rather than the 
urine may hold the indican in solution. 

Too much of the peroxid must not be added or 
else the blue color will be discharged as quickly as 
formed. A trace of indican should never be re- 
ported in a urine containing considerable albumin, 
nor should a trace of albumin be reported in a urine 
containing tremendous quantities of indican. In- 
dican has no significance as a rule in purulent infec- 
tions of the genitourinary tract for we have a local 
focus of proteid decomposition. 

Indolacetic Acid. — This is one of the acids formed 
in proteid decomposition and may be present either 
with or without indican. To 5 c.c. of the urine, add 
a drop of one per cent potassium nitrate and a few 
drops of hydrochloric acid. A pink color shows the 
presence of indolacetic acid. Its significance is 
identical with that of indican. 

Urochromogen, Significance and Detection. — ^Al- 
though a precursor of other pigments, urochromo- 
gen does not appear in the normal urine. Weiss and 
others consider the urochromogen reaction to be a 
part of the diazo test and even more sensitive than 
that devised by Ehrlich. Urochromogenuria occurs 
in late pulmonary tuberculosis, and is of prognostic 
rather than diagnostic value. It seems to argue that 
the case is hopeless; and it is useless to administer 



CHEMICAL URANALYSES 81 

tuberculins any longer. With clear, fresh urine fill 
a test tube one-third. Fill the remainder of the tube 
with distilled water. Place half of the resulting 
mixture in another tube to serve as a control. Add 
to one of the tubes, three drops of a 1-1000 solution 
of potassium permanganate; mix thoroughly and 
compare with control. A yellow color is regarded 
as a positive test. 

Diazo Reaction, Significance. — The diazo reaction 
is of great value in the early diagnosis of typhoid 
fever. It is not absolutely specific for typhoid but 
3S almost so; and fortunately appears very early in 
the course of the disease. The technic is easily and 
rapidly completed. The reaction is almost always 
present, and occurs less frequently in diseases likely 
to be mistaken for typhoid. It appears in miliary 
tuberculosis, but usually somewhat late in the 
course of the latter disease. This reaction should be 
carried out alongside the Russo and the Gruber- 
Widal agglutination test, there being between the 
three an interdependence very valuable to the diag- 
nostician. This may be expressed in a table* (see 
next page). Recently the author has found that the 
diazo is sometimes present in the paratyphoid infec- 
tions, whereas, as is well known, suspensions of the 
paratyphoid strains must be used in order to secure 
a positive agglutination reaction. Typhoid vaccina- 
tion may lead to a positive Widal in a case which is 
not typhoid, but has no effect upon the diazo test. 



*Williams, B. G. R. : Archives of Diagnosis, January, 1912. 



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84 PRACTICAL URANALYSES 

Diazo Reaction, Technic. — The following reagents 
are used: 

Diazo Reagent No. 1. — Sulphanilic acid; satu- 
rated solution in 5 per cent hydrochloric acid. 

Diazo Reagent No. 2. — Sodium nitrite; 1/2 per 
cent aqueous solution. 

Diazo Reagent No. 3. — Aqueous ammonia. 

By the aid of a pipet place into the test tube 51 
drops of the specimen, 50 drops of solution 1 and a 
single drop of solution 2. Mix thoroughly but avoid 
the formation of a foam if possible. Then quickly 
add half a dozen drops of pure ammonia, permitting 
it to flow down the inner side of the tube and out 
upon the surface of the mixture in such a way as to 
form an upper stratum. In case the diazo is pos- 
itive, a beautiful pink or rose-color will be seen at 
the junction. Shake thoroughly; the foam should 
likewise be red or pink. Later a dark green sed- 
iment may form in the liquid. Pseudotests are 
given by many medicaments, but such reactions are 
rarely pink or rose-red but are yellow. However in- 
quiry should be made into the taking of opium, 
salol, antipyrin, and so on. 

The Russo (Rosso) Reaction. — The Eusso reaction 
appears in many fevers. It is of chief value, per- 
haps, when absent because a negative test speaks 
very forcibly against the diagnosis of typhoid fever. 
The author has seen this point brought out many 
times. A typhoid state (with or without fever) in 
which the Russo is absent, is very likely to turn out 
to be a nephritis, brain tumor, meningitis, or condi- 



CHEMICAL. URANALYSES 85 

tion other tlian typhoid fever. Moreover the Russo 
is rarely or never present in miliary tuberculosis, 
and its value here is secondary only to the above. 

The Russo reagent is a 1-1000 aqueous solution of 
methylene blue. Four drops are added to 5 c.c. of 
the urine. A positive reaction is shown by the pres- 
ence of a deep emerald or mint green color. A blu- 
ish or greenish tinge is regarded as a negative re- 
action. 

Chemical Identification of Sediments. — Pus is eas- 
ily identified by the addition of a solution of caustic 
soda which causes the proteids to gel and become 
tenacious (so-called muco-pus). 

The following table (Heller) outlines the proper 
procedure for the examination of calculi : 

Heat some of the dry material on a platinum foil. 

1. It does not burn. Treat it with hydrochloric 
acid. 

A. It does not effervesce. Treat it with hy- 

drochloric acid and heat gently. 
I. It does not effervesce. Moisten some 
of the powder with a little potas- 
sium hydrate. 

a. Ammonia freed. Triple plios- 

pJiates. 

b. Ammonia not released. Earthy 

pliospliates, 
II. It does effervesce. Calcium oxalate. 

B. It does effervesce. Calcium carbonate. 



86 PRACTICAL URANALYSES 

2. It does burn. 

A. With a flame. 

I. Yellow flame with an odor as the 
burning of flesh. Fibrin. 
II. Blue flame and soon ceases. Sharp 
odor. The original powder is solu- 
ble in ammonia. Permit some of 
the solution to evaporate and ob- 
serve characteristic hexagonal 
plates. Cystin. 

B. Without a flame. 

I. Does not give murexid test. XantJiin. 
II. Gives murexid test. Treat some of the 
powder with sodium hydroxid. 

a. Ammonia is loosed. Ammonium 

urate, 

b. No ammonia freed. Uric acid. 



CHAPTER IV. 
QUANTITATIVE URANALYSES. 

Only those quaiititatiye nranalyses of diagnostic 
value have been detailed in this chapter. Certain 
other estimations are sometimes carried out but 
they give no usable clinical evidence, and for these 
the worker is referred to books on physiological 
chemistry. 

Total Solids. — Practically all methods give ap- 
proximate results only, but approximations suffice 
for clinical work. By evaporating the urine and 
weighing the residue (a laborious procedure) the 
estimation may be made, but this does not guaran- 
tee absolute accuracy inasmuch as ammonia is 
driven off. 

The method which is most satisfactory for clinical 
purposes is as follows : Multiply the last two figures 
of the specific gravity by the number of fluid ounces 
excretion in the twenty-four hours and the result in 
turn by 1.1, which gives the total solids in grains. 
This figure divided by 15, gives the reading in 
grams. Normally the solids each twenty-four hours, 
vary betAveen 40-80 grams, but 64 grams is the aver- 
age in urines of perfectly healthy individuals. The 
following example will make this method clear. 
Suppose the patient passes 45 fluid ounces of urine 

87 



88 PRACTICAL URANALYSES 

daily, and the specific gravity of the mixed spec- 
imen is 1019. 

(45X19X1.1) -^ 15 = 62.7 grams. 

Normal Quantitative Composition. — The follow- 
ing table expresses approximately in terms of 
grams, . the solid composition of the urine each 
twenty-four hours : 

Urea 35. 

Chlorids 12. 

Acid phosphoric 5. 

Acid sulphuric 3. 

Earthy phosphates 1.5 

Acid uric 1.5 

Creatinin 1.5 

Acid hippuric 1.5 

Ammonia, iron, pigments, etc 3. 

Total 64. 

Keep in mind, however, that these figures are ap- 
proximate even in health, since diet and other fac- 
tors subject them to great variations. In a bedfast 
person the total solids are greatly decreased and it 
is not unusual to find but 20 grams of urea in such 
a person even though there is no renal lesion. 

Chlorids. — Man excretes from 10 to 14 grams of 
common salt by his kidney each twenty-four hours. 
This amount is lowered by a reduction of certain 
foods which contain salt, and is increased vice versa. 
Eegardless of the amount taken as food, the chlo- 
rids are decreased in acute fevers and in certain 
forms of nephritis. In pneumonia, the urine may 
become practically salt-free, but tremendous quan- 



QUANTITATIVE URANALYSES 89 

titles are again passed just preceding the crisis. In 
suspected nephritis where the food is rich in salt, a 
low excretion is presumptive of kidney injury (re- 
tention of chlorids). This contention has been dis- 
puted upon theoretical grounds, but observation in 
• a large number of cases will convince that '^chlorid 
retention'' may occur before albuminuria and cylin- 
druria and many months before urea retention can 
be proved. In such cases, foods containing salt 
should be reduced ; and salt should not be used for 
seasoning inasmuch as the retention of sodium chlo- 
rid in the tissues favors edema and other serious 
complications. 

Coarse Method. — This answers very well in many 
cases. Remove albumin by heat and filtration when 
necessary. Filter in case the urine is not transpar- 
ent. To 10 c.c. of the urine, add four drops of 10 
per cent silver nitrate solution. Thick, curdy pre- 
cipitate indicates normal chlorids while a mere milk- 
iness is proof of diminution. Use control of a nor- 
mal urine in this test. 

Titration Method. — The following reagents are 
prepared : 

Reagent No. 1. — Dissolve 29.06 grams of pure sil- 
ver nitrate in one liter of distilled water. One c.c. 
of this solution corresponds to .01 gram of sodium 
chlorid (or each c.c. corresponds to 10 milligrams of 
sodium chlorid). 

Reagent No, 2, — A saturated, chlorin-free solution 
of potassium chroniate (yellow). This serves as in- 
dicator. 



90 PRACTICAL URANALYSES 

Method. — Eemove albumin if necessary. Place in 
each of two large evaporating dishes, exactly 10 c.c. 
of the urine, two drops of indicator and enough dis- 
tilled water to make up 100 c.c. To dish one, we 
add drop by drop, from a buret the Reagent I, un- 
til in spite of stirring Avith a glass rod, a faint red 
or pink color becomes perceptible. This may be 
recognized more quickly by contrast with the urine 
in the control dish. The buret reading is then 
taken. (A drop or two of the silver will make per- 
manent the red color and show that the above read- 
ing was correct.) Having determined the sodium 
chlorid present in 10 c.c. of the urine, it is easy to 
calculate the amount present in the twenty-four 
hour sample. 

For example : 

Amount of urine per twenty-four hoursz=:1200 c.c. 
Amount of reagent used to the 10 c.c. of urinezz=12 c.c. 
Amount of sodium chlorid present in 10 c.c. of urine:zr:.12G. 
Sodium chlorid present in twenty-four hour sample=:14.4 G. 

Phosphates. — Of much less practical importance 
is the determination of total phosphates. The clin- 
ical significance of the so-called ^ ^ phosphaturias ^ ' is 
not clear. Inasmuch as reliable quantitative meth- 
ods are complicated and afford no diagnostic data, 
it has seemed best to omit them from this volume. 
A few words are pertinent. To phosphates (acid or 
alkaline salts) is due the normal urinary reaction. 
Certain cases of '^phosphatic diabetes^' have been 
studied. Clinical phosphaturia (earthy phosphates 
in large amounts with a fixed alkalinity of the 



QUANTITATIVE URANALYSES 91 

urine) occurs in certain functional nervous diseases. 
Von Noorden has shown that phosphates even in 
normal amounts irritates diseased kidney paren- 
chyma, but this holds perhaps in the case of most 
of the inorganic urinary salts. 

Sulphates. — For practical purposes it is not nec- 
essary to titrate for total sulphates. Where ethereal 
increase is sufficient to demand clinical considera- 
tions, the indicans are present and may be detected 
by simple color tests. 

Total Nitrogen. — ^^In routine work, the estimation 
of the total nitrogen is not necessary. Because of 
the fact that a certain quantity of the nitrogen of 
the food and perhaps also of tissue metabolism, es- 
capes by the bowel, the total nitrogen of the urine 
cannot be regarded as an absolute index of proteid 
metabolism. Inasmuch as urea bears an almost con- 
stant ratio to the total nitrogen and inasmuch as it 
is eliminated almost entirely by the urine when the 
kidneys are not seriously diseased, urea estimations 
are of far greater importance. 

The waste nitrogen of the food and of tissue 
metabolism is excreted as urea, ammonia, uric acid, 
creatinin and amino-acids (the latter with ammonia, 
especially where there is a disturbed formation of 
urea as in hepatic disease). 

Ammonia and Amino-acids. — Urea is the non- 
poisonous synthetic resulting when carbon dioxid 
and ammonia (two poisonous, waste-products of 
katabolism) are united in the liver. In certain 
hepatic diseases, this elaboration is effected only in 



92 PRACTICAL URANALYSES 

part or not at all, and in consequence much of the 
urinary nitrogen occurs as ammonia and amino- 
acids rather than urea. Then, too, in acidosis and 
certain acidemias the ammonia is used to neutralize 
the poisonous acids that the fixed alkalies of the tis- 
sues may be spared. Being, therefore unavailable 
for the synthesis in the liver, the urea is decreased 
in diabetes and similar affections. 

Ammonia occurs in the normal urine, about .9 
grams being excreted daily. Various methods for 
estimating the urinary ammonia, have been sug- 
gested. Any of those approaching simplicity are 
inaccurate. As a matter of fact we know that in 
cases where ammonia estimations are likely to prove 
of value, the urea is considerably lowered, and this 
is evidence presumptive, providing we are able to 
rule out urea retention of kidney lesion. Moreover 
titration shows excessive acidity in many of these 
cases. As a rule it is best to leave ammonia studies 
to the research worker and large laboratories, and 
give chief attention to urea. 

Ammonia Estimation. — A fairly accurate method 
is that of Schlosing, though the readings are usually 
a bit too low. The urine should be fresh, or if sent 
to a laboratory, five drops of 5 per cent potassium 
fluoride should be added to prevent the breaking up 
of urea into ammonia. The mouth of a bell jar is 
ground and fitted to a ground glass plate. The edge 
is smeared with tallow to prevent the entrance of 
air. A Petri dish containing 10 c.c. of decinormal 
sulphuric acid is placed on the center of the plate. 



QUANTITATIVE URANALYSES 93 

On this in turn is placed a triangle bearing a beaker 
containing 20 c.c. of the urine. To this urine is 
added 20 c.c. of milk of lime. The bell jar is placed 
over the whole to make the chamber air-tight. 
After forty-eight hours the acid is titrated and thus 
the amount of ammonia absorbed is ascertained. 

Urea. — ^Having thus placed chief stress upon the 
value of the urea estimation, it is very necessary 
that this be made as accurately as possible. Prop- 
erly mixed and preserved twenty-four hour spec- 
imens should be used, as the urea excretion varies 
from hour to hour and percentage readings from 
single specimens are likely to mislead. 

The methods which in the hands of the author 
have given the best results are those of Doremus 
and of Squibb. With the latter apparatus, details 
and charts are supplied, so that a description is not 
necessary here. 

The Doremus estimation is made as follows : Make 
up a solution of sodium hydroxid, 100 grams to 250 
c.c. of distilled water. This is a stock solution and 
must be closed with a rubber stopper. When ready 
for the test, pour into the Doremus ureometer 
euough of this hydroxid solution to fill the tube to 
the mark ''=." Now by means of the pipet which 
accompanies, the instrument, add one c.c. of pure 
bromin to the hydroxid solution. When this has 
been dissolved, dilute by pouring in distilled water 
until the long arm and the bend of the ureometer 
are filled. When the proper amount is added, the 
liquid should be thoroughly luted at the bend of the 



94 



PRACTICAL URANALYSES 



arm and no air remain in the long arm when the 
instrument is upright. By properly tilting the in- 
strument during this manipulation, this may be 
done. Take 1 e.c. of the urine in the clean, curved 
pipet, immerse the tip under the bend in the tube 




Fig. 3. — Doremus-Hinds ureometer. 



and discharge all of this urine into the hypobromite, 
being careful that air does not enter either from the 
air behind the urine column or from the outside of 
the tube by improperly tilting. Permit the ap- 
paratus to stand thirty minutes. Then read amount 
of solution displaced (in terms of grams). 



QUANTITATIVE URANALYSES 9-5 

It is easy to calculate for the twenty-four hours. 
For example suppose that the reading for 1 c.c. is 
.023 grams. The twenty-four-hour quantity of urea 
is 1500 c.c. By simple multiplication the total quan- 
tity of urea is 34.5 grams. Highly concentrated 
urines may need to be diluted with known amounts 
of distilled water, to be used with this instrument. 
When buying a Doremus ureometer, request the 
French system of marking if the above directions 
are to be followed. The English ureometer gives 
the readings in grains. 

The twenty-four hours ^ urea estimation is the 
best laboratory procedure to determine the func- 
tional activity and possibilities of the kidneys ; i. e., 
just how much work they are doing. Special meth- 
ods must be used in surgical kidney where the func- 
tion of the single organ is in question, or it is nec- 
essary to determine Avhich of the two is diseased. 

Uric Acid.— Anent the so-called ''diatheses,'' it 
may be said that in gout and certain other disor- 
ders, uric acid has borne the blame for many years. 
There can be no question but that uric acid deposi- 
tion plays a part in true gout ; but this part is, per- 
haps, secondary. But the various forms of arthritis 
and the like, formerly attributed to uric acid ''dia- 
thesis,'' have been seized upon by the pathologist 
and properly placed under other heads, notably un- 
der the infectious toxemias. So far as the uranal- 
ysis is concerned in gout, especially in acute gout, 
the uric acid excretion is reduced, except at periods 
when it is excessive. To be sure, the uric acid in the 



96 PRACTICAL URANALYSES 

blood is high, but by no means higher than in other 
chronic diseases or indeed than after a heavy pro- 
teid meal. It may be advisable to keep tab on the 
uric acid excretion in gout (especially as regards 
certain diets or drug treatments) and for this rea- 
son the following method for estimation may be 
detailed : 

Euhemann's uricometer is recommended for rou- 
tine clinical work. The reagent consists of iodin 1.5 
grams, potassium iodid 1.5 grams, and 15 grams of 
absolute alcohol in 185 c.c. of distilled water. The 
test is set up by filling the instrument to the first 
line ^'S'^ with carbon bisulphid. Then by means of 
a pipet, Ruhemann's reagent is added until it stands 
at the next mark ^^I." On this is allowed to run 
the urine (which should be at a temperature of 65 
degrees F.) until it stands at the lower part of the 
graduated scale marked 2.45. This is best accom- 
plished by means of a pipet. The open end of the 
instrument is then closed by the stopper and the 
tube shaken. The carbon bisulphid becomes brown. 
Eemove the stopper and add more urine. Shake 
and observe the bisulphid. Cautiously repeat the 
process until the bisulphid becomes w^hite. Then 
read the upper level of the liquid which shows in 
grams the amount of uric acid per 1000 c.c. of urine. 
Alkaline urines must be acidified slightly with 
acetic acid before the test is set up. Likewise if al- 
bumin is present, it must first be removed by heat 
and filtration. Where there is very little uric acid, 
it may be imperative to add the iodin reagent but 



QUANTITATIVE URANALYSES 97 

to the line midway between ^^S^' and '^I'' and di- 
vide the reading by half. 

Nowadays the physician will have bnt little use 
for the uric acid reading, since the clinical signifi- 
cance of the estimation has been shorn of its former 
glory. 

Oxalic Acid. — Clinical oxaluria, that is an 
oxaluria causing local symptoms (oxaluria dolo- 
rosa), is diagnosticated by finding the minute crys- 
tals of calcium oxalate in the freshly voided urine. 
True oxaluria is detected by quantitative estima- 
tion of the oxalic acid of the urine. Inasmuch as it 
has been shown that either condition may exist 
Avithout the other, the quantitative estimation of 
oxalic acid is not called for in routine diagnostic 
work. 

Indican. — Indican is a strictly abnormal urinary 
finding, and the success of a treatment is best shown 
by the absolute disappearance of indican from the 
urine. Color charts are of some value in determin- 
ing indican decrease, but offer no advantage over 
the scheme of w^atching the chloroform becoming 
lighter blue in color and finally colorless when indi- 
can is absent. 

Diacetic Acid. — The same applies to diacetic acid. 
There may be a profound diabetic coma with but 
little diacetic acid in the urine, and a trace is dis- 
tinctly pathological. These tests are usually classi- 
fied as to degree by the intensity of the color as 
follows : overplus, decided, moderate, small amount, 



98 



PRACTICAL URANALYSES 



-R 



and none. For practical purposes, this nomencla- 
ture is sufficient. 

Serum Albumin. — Here as elsewhere the test of a 
single voiding is valueless. The amount of albumin 
may vary from hour to hour. More- 
over a urine may show a lower per cent 
than at a previous examination because 
more urine is being passed. Quacks 
have made use of the percentage test 
in connection with the administration 
of diuretics to demonstrate the ef- 
ficiency of the latter; but a series of 
twenty-four hour computations will 
show whether or not albumin has actu- 
ally decreased. Finally we are not 
certain that decrease of albumin is a 
favorable prognostic item, inasmuch as 
albuminuria may depend not alone 
upon the nephritis but upon circulatory 
changes and so on, and albumin may 
decrease in amount just before the fatal 
issue, although an increase is the 
rule. 

Roughly, albumin coagula may be 

classified as putty-like masses, distinct 

coagula or flakes, milkoid liquid and 

mere fogginess. 

The volumetric calculation of serum albumin is 

usually made by Esbach's method. These albumin- 

ometers are easily secured from all jobbers. The re- 



U 



— 7 

— 6 
—5 

— * 

— 3 



Fig. 4. — Esbach 
albuminometer. 



QUANTITATIVE URANALYSES 99 

agent is made up by dissolving in one liter of dis- 
tilled water, 10 grams of picric acid and 20 grams 
of citric acid. The test is set up by filling the tube 
to the mark ^^U" with some of the mixed twenty- 
four hour urine specimen (filtered if not transpar- 
ent) and adding the reagent to the mark '^E.'' The 
tube is corked with a rubber stopper and the con- 
tents thoroughly mixed by inverting several times. 
It is then set aside for twenty-four hours in a per- 
fectly vertical position. The reading is made at the 
highest point reached by the sediment. This shows 
the number of grams of serum albumin to each 1000 
c.c. of the urine. For the twenty-four hour spec- 
imen the calculation may be easily made by sub- 
stituting in the following equation : 

x=grams of albumin per twenty-four hours. 

ac=quantity urine passed in twenty-four hours. 

b=reading on albuminometer. 

1000:a::b:x. 
For example: 

a— 1500 c.c. 

b=:4. 
Substituting : 

1000:1500: :4:x. 

x=z:6 grams. 

A rapid method has been proposed for the Esbach 
test whereby readings may be made in a few min- 
utes. 10 drops of a ten per cent ferric chlorid 
solution are added to the urine after it has been 
placed in the Esbach tube to the mark ''U.'' Then 
the Esbach reagent is added to the mark ''E." The 
tube is stoppered and the contents mixed as before. 
Finally place the tube perfectly uprigJit in a water 



100 



PRACTICAL URANALYSES 



bath at 70'' C. Coagulation will be complete in 15 
minutes as a rule. The results are accurate. 

Glucose. — The chemical methods for the exact es- 
timation of glucose give variable results in the 
hands of the average worker. This is due to the 
fact that considerable practice and pains are neces- 
sary to recognize the exact point of total reduction. 




Fig. 5. — Kinhorn saccharometer. 



Although the fermentation method takes longer for 
its completion, it is easily done and results are quite 
accurate if directions are followed. On the Einhorn 
saccharometer (saccharimeter) the graduations are 
such that the amount of carbon dioxid loosed may 
be read off as per cent of glucose. If there is more 
than a trace of glucose in the urine (as shown by in- 



QUANTITATIVE URANALYSES 101 

creased specific gravity and preliminary tests), the 
urine should be diluted 10 times with distilled wa- 
ter, multiplying the reading of course by 10 to get 
the proper final result. 

Fermentation Test. — Acidify the urine if neces- 
sary. Shake a small amount of the urine with ap- 
proximately 10 grains of fresh compressed yeast. 
Pour the mixture into the saccharometer in such a 
T\'ay that no air is left in the long arm. Place in 
an incubator or at incubator heat for twenty-four 
hours or until no more gas bubbles are given off 
(twelve hours often suffice). Not only will a lower 
temperature retard fermentation, but it must be re- 
called that the volume of a gas A^aries with the tem- 
perature. (In a cold room the readings will be too 
low.) It is best to set up controls Avith normal 
urine and urine to which glucose has been added, 
which will show whether or not the yeast ferments 
itself (contains glucose), and to what degree; and 
whether or not it is really active. 

The following precautions must be kept in mind : 

1. Urine must be slightly acidified unless already 
acid. 

2. Must be properly diluted if there is more than 
a trace of glucose. 

3. Do not shake too ivell the yeast and urine. 
Although mixture should be fairly complete, con- 
tinued shaking will include many air bubbles. If 
the yeast settles before fermentation begins, mix 
gently. 



102 PRACTICAL URANALYSES 

4. Keep at or near 37° C. for the reasons given 
above. 

5. Use the controls mentioned above to test yeast 
activity and glucose presence in yeast. 

6. Anent urinary antiseptics, it has been claimed 
that after the administration of drugs of the aro- 
matic series, heavy metals, hexamethylenamin and 
even some of the alkaloids, fermentation may be 
thwarted. 

7. Do not be misled by the figures etched on the 
right hand of the scale : these refer to the capacity 
of the tube in cubic centimeters. Readings are 
made froDi the figures on the left. 

8. Finally do not forget to multiply by the 
proper figure if the urine has been diluted. 

Haines' Test. — This is the best of the chemical 
quantitative methods, but it is suggested that con- 
siderable experience is necessary in the correct ap- 
plication for the reasons given above. For this cal- 
culation, a special Haines reagent is made up as fol- 
lows : 

Copper sulphate, C. P 8.314 grains. 

Potassium hydroxid, C. P. . . 25.000 grams. 

Ammonia (pure) 350.000 c.c. 

Glycerine 40.000 c.c. 

Aqua destill 1000.000 c.c. 

Into an Erlenmeyer flask, measure 10 c.c. of this 
solution and add 70 c.c. of distilled water. Boil the 
mixture steadily, adding carefully from a buret the 
urine drop by drop, until the color begins to fade 
to a light blue. Now add each drop very carefully, 
shaking the contents somewhat after each drop is 



QUANTITATIVE URANALYSES 103 

added and waiting a few seconds to see if the color 
is entirely discharged. AVhen finally the urine is 
quite colorless, the end reaction has been reached 
and the reading may be made from the buret. 10 
c.c. of the Haines solution are decolorized by .01 
gram of glucose. 

Suppose for example 3.5 c.c. of the urine were re- 
quired to decolorize. Then 3.5 c.c. of the urine con- 
tains .0028 grams of glucose. Multiplying by 100 
will give the glucose percentage, which in this case 
would be .28 per cent. 



CHAPTER V. 
MICROSCOPIC URANALYSES 

Upon standing, certain of the urinary constitu- 
ents are deposited. Sometimes this takes place 
rapidly, at other times after several hours. Many 
urines contain constituents which have never been 
in solution (cell, casts, and so on) while in the case 
of others, the deposition may have occurred in the 
upper passages (oxalates) or in the bladder (amor- 
phous urates). Moreover it must be kept in mind 
that the specimen may contain matter from the 
genital organs, alimentary tract or skin. Certain 
extraneous substances as dirt, cotton fibers, hairs, 
starch grains and so on may find their way into the 
specimen. 

The Nubecula. — Soon after a urine has been 
passed, it may be noted that it is not perfectly trans- 
parent. The cloudy deposit, or nubecula is made up 
of mucus and a few cells from the urinary passages. 
In this mucus reticulum, specific pathological finds 
may be suspended. Now and then it may happen 
that the cloud rises to the surface, bearing in its in- 
terstices these important elements. But usually 
the ^^ urinary sediment'^ sinks to the bottom of the 
specimen or may be throw^n down by centrifugaliza- 
tion. 

104 



MICROSCOPIC URANALYSES 105 

Centrifugalization. — Centrifugalization may lead 
to the morphological alteration of certain of the 
urinary constituents, but centrifugalization is usu- 
ally preferred to sedimentation for the following 
reasons : 

1. Urines should be examined fresh because some 
urines contain pepsin which dissolve casts and other 
organic constituents. 

2. Because of changes due to fermentation. The 
alterations incident to ammoniacal decomposition 
render microscopy unsatisfactory. 




Fig. 6. — Sedimentation glass. 

3. Urines upon standing undergo certain changes 
even though there is no fermentation. Thus certain 
salts are thrown down — urates, oxalates, and so on. 

4. Some sediments are not sediments in fact, but 
remain suspended in the urine or actually rise to the 
surface and may be secured only by centrifugaliza- 
tion. 

In some cases the use of preservatives with sedi- 
mentation may be used to control questionable finds 
with centrifugalization. For preservatives see page 
20. Delepine has recommended refrigeration to 
prevent the decomposition of urine, but it must be 



106 PRACTICAL URANALYSES 

remembered that decreasing the temperature of a 
urine favors the deposition of certain sediments 
notably the amorphous urates which tend to obscure 
more important finds as the occasional cast or renal 
cell. 

Practical Microscopy. — A small amount of the 
sediment is removed from the bottom of the sedi- 
mentation glass or centrifuge tube as follows. A 



Fig. 7. — Water centrifuge. 

pipet is pushed into the sediment, the larger end be- 
ing closed tightly by the finger. Slightly release the 
pressure of the finger permitting a small amount of 
the sediment to enter the pipet, and then close tight- 
ly again and remove the pipet. A drop of the sedi- 
ment may be secured by releasing the pressure of 
the finger. This may be dropped on a slide and a 
cover-glass placed upon it for examination. The 



MICROSCOPIC URANALYSES 107 

point of the pipet should not come into contact with 
the slide, for more or less than a drop of the sedi- 
ment will be obtained. The drop should drop or 
fall upon the glass. If too much sediment is secured 
the cover-glass cannot conceal it and the lighter 
sediment, as casts, will be forced beyond the edge of 
the cover, and hence missed in the examination. 
Or if large drops must be examined, very large 
cover-glasses may be used. 

The ordinary glass slide does not answer the 
purpose so well in routine work as a piece of win- 
dow glass cut to the dimensions of 2 inches by 4 
inches. 

Many important sediments are missed because the 
microscopist uses too much light. After securing 
the illumination and the proper focus, it is well to 
narrow the iris diaphragm until the best view of 
the sediment is secured. A twilight illumination is 
best for most sediments. 

Some sediments are examined with difficulty. Thus 
ammoniacal fermentation may not only result in the 
disintegration of cells and casts, but the latter may 
be obscured by the mineral sediments thrown down 
in large quantity. Excessive amounts of blood or 
pus may hide a few casts or renal cells, and it is 
sometimes best to make examinations when the 
urine is comparatively free from blood or pus. . 

CHEMICAL SEDIMENTS 

Sediments are usually classified as mineral and 
organic. Unorganized and organized, is the nomen- 



108 PRACTICAL URANALYSES 

clature preferred by some authors, and is to be 
preferred because oxalates, urates and so on (truly 
organic compounds) must be placed with the min- 
eral sediments to differentiate from cells, casts, and 
so on. The terms, chemical and biological sedi- 
ments have their shortcomings, but are perhaps best 
of all. 

Uric Acid. — Of chemical urinary sediments, the 
form of the uric acid crystal varies most of all. The 
size and color also varies. The barrel or whetstone 
crystal is the common type. Spears, dumb-bells, 
double wedges, and bars are also found. The sepa- 
rate cr3^stals may be arranged in peculiar rosettes, 
sunflower^, and other strange groupings. In case 
of question, the yellow or orange color, typical 
whetstones or chemical reactions (see page 85) 
may make their identification possible. In some 
cases color may be absent or erosion may alter the 
shape of the crystals. 

Uric acid crystals are very heavy and may often 
be observed by the naked eye as red, sand-like 
masses in the bottom of the specimen. 

Urates. — These appear as amorphous masses vary- 
ing in color — white, pink (or salmon tinted), 
orange, yellow or even rose-red but never bright red 
as the uric acid deposit. When examined micro- 
scopically they rarely show any color. They are 
easily differentiated from amorphous earthy phos- 
phates by heating the urine. Urates go into solution 
before the boiling point is reached, while the phos- 



MICROSCOPIC URANALYSES 



109 



phates do not but are likely to become even more 
dense. 

Ammonium urate is sometimes found in urines 
undergoing ammoniacal decomposition. It appears 
as spheres with projecting spines and is often 
likened to the cockle-bur. The clinical significance 
of the uric acid and the urates has been considered 
(see page 40). 

Phosphates. — Earthy (calcium and magnesium) 
phosphates occur in alkaline urines or may be pre- 




Fig. 8. — Common crystals found in urinary sediments. A, uric acid; 
B, ammonium urate; C, calcium oxalate; D, triple phosphate; K, calcium 
carbonate. 



eipitated from such b}^ heating. They appear alone 
when the alkalinity is fixed, but are accompanied by 
the triple phosphates where there is a volatile (am- 
moniacal) alkalinity. They are amorphous in ap- 
pearance and may be confused with the urates. 
They are discriminated by the heat test. 

Triple phosphates (ammonium-magnesium phos- 
phate) may appear when the urinary ammonia is 
increased, but are more likely to be met in ammo- 



110 PRACTICAL URANALYSES 

niacal fermentation. They are proof of a volatile al- 
kalinity. Their size varies and they are colorless as 
a rule. They appear as coffln-lids (prisms having 
oblique terminal surfaces). They are readily sol- 
uble in dilute acid, which will differentiate them 
from the oxalates. 

Stellar phosphates may occasionally be found in 
neutral urines. The unit crystals are rod-like or 
prismatic, either tapering at one end or beveled 
like a mortise chisel. They are often grouped as 
fascicles, stars and fans. 

Oxalates. — Calcium oxalate appears usually as 
envelopes (octahedra in which the principal axis is 
short). At times they may resemble the small coffin- 
lids of triple phosphates, but the latter are soluble 
in dilute acid Avhereas the former are not. By vir- 
tue of rapid precipitation or erosion, the form may 
vary from this type; and we meet Avith biscuits, 
hour-glasses, dumb-bells, plates, and so on. In pain- 
ful oxaluria (oxaluria dolorosa) the crystals may 
appear as delicate needles (rapid precipitation in 
vivo). 

Carbonates. — Deposition of calcium carbonate is 
usually incidental to alkaline fermentation where 
the carbon dioxid loosed unites with what calcium 
it may find available. The sediment is amorphous, 
and cannot be differentiated by the microscope but 
by the addition of acid. The effervescence resulting 
is due to the fact that the compound is again split 
into carbon dioxid gas and acid salts of calcium. 

Close examination will show that the amorphous 



MICROSCOPIC URANALYSES 



111 






X%t^. 







Cyst in. 




f^oO^ 




CaJcium Carbonate. 



Hippuric Add. 



Calcium Oxalate, 




vfi[^'i-;^.«^^i 




Calcium Phosphate 




Calcium Sulfate 




Leucin and Tyrosin. 



% 



Magnesium Phosphate. 



Fig. 9. — Urinary sediments. — (After Tyson, Holland, Casselman, 
I^andois, -Beale, and v. Jaksch.) 



112 PRACTICAL URANALYSES 

calcium carbonate is composed of minute spheres; 
but the urates may take a similar form. It has been 
suggested that the former spheres usuall}^ unite to 
form minute dumb-bells while the latter do not ; but 
minute calcium oxalate crystals may present a sim- 
ilar appearance, so that chemical rather than mi- 
croscopical differentiation is usually more satisfac- 
tory. 

Sulphates. — Calcium sulphate occurs very rarely 
in the urinary sediment. Its crystals resemble the 
stellar phosphates, but are insoluble in dilute acid. 

Cystin. — This sediment occurs as thin, noncolored, 
six-sided plates. Some of the crystals show a single 
notch as if they had been hacked. Crystals of cys- 
tin may be mistaken for uric acid and vice versa. 
A drop of hydrochloric acid may dissolve the cystin 
but not the uric acid. The latter are usually yellow 
and typical whetstones may be found as a rule. 
Cystin occurs in normal urine but is usually in so- 
lution. "When crystals are found, cystin calculi are 
to be suspected. Cystin in overplus quantities gives 
evidence of perverted metabolism, but the exact na- 
ture of such is not well understood. The marked 
tendency of these crystals to imbrication is thought 
to explain the invariable calculus formation inci- 
dent to their appearance in the urine. Delepine 
seems to have shown by experiment that some cases 
of cystinuria are due to processes of fermentation 
(not thoroughly worked out) occurring in the uri- 
nary tract. The observation is not .trivial, and may 
have much to do with the treatment. The author 



MICROSCOPIC URANALYSES 113 

has contended that certain cases of painful oxaluria 
may be explained by fermentations in the urinary 
tract. Urotropin has been shown to exert a favor- 
able influence in cases of ' ^ gravel. ' ' The author has 
observed one case of cystinuria in a feeble-minded 
girl, where calcium sulphate also entered into the 
composition of the calculus. 

Leucin and Tyrosin. — The presence of amino- 
acids in a perfectly normal urine is doubted. They 
occur in traces in some urines which show no albu- 
min, glucose or casts, but this does not signify that 
such urines were not pathological. However in cer- 
tain diseases of the liver a variable quantity of the 
waste nitrogen may occur as leucin and tyrosin 
rather than urea. In the toxemia of certain diseases 
as typhoid, these mono-amino-acids appear in traces, 
but in the more severe liver diseases as acute yellow 
atrophy, large amounts of these bodies may be pres- 
ent, and urea appear only in traces or not at all. 

Tyrosin in the urine is soluble but slightly ; leucin, 
easily. The amount of either, therefore, which will 
appear as crystals, depends not only upon the actual 
quantity eliminated but mainly upon the urinary 
concentration. Fortunately for the microscopist, the 
urine is usually highly concentrated in these cases. 
But to get them to separate out (and this applies es- 
pecially to leucin), it may be necessary to evapo- 
rate the urine to a syrup. As a rule this is best 
done by placing a drop of the urine on a slide and 
evaporating over flame (do not heat too rapidly). 
A cover-glass is then added and the examination 



114 



PRACTICAL URANALYSES 




fsa 



Phosphates, Triple. Ammonio- 
magnesium Phosphate. 



® © •c ^ ©o 







v*.**^ 



m^if 



Urates of Sodium A 



@ 






I^^l 




^ 



Acid Fermentation. 







Epithelium 



Fig. 10. — Urinary sediments. — (After Tyson, Holland, Casselman, 
I^andois, Beale, and v. Jaksch.) 



MICROSCOPIC URAXALYSES 115 

made. Tyrosin appears as fine needles and leucin 
as spheroids bearing delicate circular and radial 
striations. Either may be colorless or contain 
urinary pigments. Tyrosin is insoluble in ether, 
but soluble in dilute acids; and thus easily differ- 
entiated from fatty needles. 

Other Chemical Sediments. — Cholesterin occurs as 
thin plates presenting staircase irregularities or 
gaps on their edges. Treated with dilute sulphuric 
acid and iodin, they assume beautiful blue, violet, 
green, yellow and reddish tints. In several thou- 
sand uranalyses, the author has never come across 
cholesterin crystals and cannot believe that they 
occur very often in a sediment. Whether or not 
they are ever found in the routine examination, 
their clinical importance approaches nil. The same 
may be said of xanthin and hippuric acid often de- 
scribed in the texts. Blood and bile pigments are 
often deposited in the urine but are identified by 
chemical rather than microscopical methods. Very 
occasionally pure indigo has been found in fresh 
and fermenting urines, but usually it appears as 
indican. 

BIOLOGICAL SEDIMENTS. 

Kidney Cells. — The physiological importance of 
the renal cell*, forming as it does the ultimate unit 
of the secreting parenchyma, must be great indeed. 
Moreover the pathologist warns us that while to a 
certain point there may be compensatory functiona- 



*Williams, B. G. R. : American Medicine, September, 1913. 



116 PRACTICAL URANALYSES 

tion of the remaining cells or partial repair of those 
not entirely destroyed, that time regeneration of 
lost renal cells never takes place. And yet upon 
looking over texts, one must be struck with the lack 
of emphasis placed upon the presence of the kidney 
cell in urinary sediments. 

When man passes his zenith, we are not surprised 
to find in his urine an occasional hyalin cast, for 
hyalin casts show no serious retrograde process in 
the kidney. Strangely enough, however, the diag- 
nostician talks casts and rarely mentions the cell 
from the uriniferous tubule, when but a moment's 
reflection would impress upon him the fact that in 
any quantity, free or in casts, it must be considered 
as proof of actual and irreparable kidney injury and 
that disease of the parenchyma is undoubted. We 
do not know just how many of these cells we can 
lose and survive, but comprehending that there 
must be a limit, the actual number of renal cells per 
twenty-four hours, is of much greater importance 
than the actual number of casts. Moreover many 
renal cells lost do not appear as such in the sedi- 
ment, but may be noted as protoplasmic debris 
(granules, fragments, etc.). 

Claim has been made that only such renal epithe- 
lium as comes from the ducts may be recognized in 
the urine, those cells having their origin in the con- 
voluted tubules being so altered by their longer stay 
in the urine as to render identification highly im- 
probable. This unjustified statement has been cop- 
ied into most texts. After all, the tubule is very short 



MICROSCOPIC URANALYSES 117 

as compared with the remainder of the tract, and 
in some cases the cells are remarkably well pre- 
served even after specimens have been sent by par- 
cel post for long distances. The absurdity is bnt 
one of many appearing in books on nranalysis. The 
presence of pigmented renal cells found in bilirXibi- 
nuria at least, may be more easily explained by 
actual injury during secretion than any which 
might result from contact with the cuticulated cells 
further down. 

Martin Fischer suggests . that there is solution 
of the cement substance (membrana propria), and 
the cells easily slip off into the lumina of the 
tubules. If in some of the diseased tubules there 
is as yet no considerable stagnation of the urine, it 
is eas}^ to see how almost perfect secretory cells may 
be recovered from and identified in the urinary sed- 
iment. Those who are not willing to accept the dic- 
tum that all the nephritides are parenchymatous, 
may explain the showers of w^ell preserved cells in 
the urine even though there is not a simultaneous 
increase of casts and serum albumin. In other 
words, the pathological changes in the interstitial 
tissue have almost run their course, active inflam- 
mation has practically ceased but the connective 
tissue is contracting and the uninvolved, secretory 
units though willing to work a bit longer are me- 
chanically dislodged and float away in the urinary 
stream. 

It is probable, how^ever that the first explanation 
will suffice for most cases of renal cell desquama- 



118 PRACTICAL URANALYSES 

lion. Fischer has apparently shown that whether 
by selective absorption or by protoplasmic combina- 
tion into permanent chemical union, certain poison- 
ous acids are retained in the secreting cells and not 
eliminated by the urine. Some of the cells undergo 
degenerations, necroses and cytolysis by virtue of 
this retention, so that in the sediment may often be 
found diseased as well as apparently intact cells. 
In fact from what we know of epithelial cells in 
general, Ave are led to believe that alterations in 
the renal cells of the sediment are (except in badly 
decomposing urines) distinctly pathological. Upon 
these and other findings, the alkaline treatment of 
the epithelial nephritides has been proposed by 
Fischer. Any osmotic influences exerted by the 
urine upon the cells, would be evident not by degen- 
erations, necroses and fragmentations, but by a 
swollen or shrunken appearance. As has been 
stated, hoAvever, the solid construction of the epi- 
thelial cell renders artifacts unlikely. 

The higher poAver objectiA^es are necessary to 
identify the renal cell just as the loAver poAvers are 
best for casts. Centrifugalized specimens are of 
course to be preferred unless there are very many 
cells (a distinction from the method of preparing 
specimens containing pus cells AA^here centrifugal- 
ization results in misshaping these delicate ele- 
ments). 

The renal cells may appear singly or in groups, 
free or in the cast makeup. In mercurial nephritis 
the entire linings of the tubes may be shed, and usu- 



MICROSCOPIC URAXALYSES 119 

ally collapsed, pass for true, epithelial casts in the 
hurried examination. The cells may not be well 
preserved but inanimate, degenerated, necrotic or 
even fragmenting. By the use of Sudan iii, fatty 
granules may be identified in the protoplasm. 
Stained spreads are rarely satisfactory; first be- 
cause urinary sediments are not easily fixed to the 
slide, second because artifacts result from the ex- 
cessive concentration of the salts during drying. 

In bilirubinuria these cells are often pigmented, 
and pigmented renal cells should ahvays lead the 
physician to test very closely for bilirubin because 
these elements rarely or never take up uroerythrin. 

"When well preserA^ed, the renal cell is epithelial 
or hyalin-like in appearance. AVhen it contains de- 
generation granules it may resemble the pus cell. 

In size, the cell from the uriniferous tubule ap- 
proximates that of the pus cell — approximates since 
ic may be somewhat larger or even smaller (in some 
instances more nearly the size of the erythrocytes). 
A cell almost double the size of the pus cell comes 
more likely from the larger collecting tubules, re- 
nal pelvis, or even the ureter. Discrimination be- 
tween the pus cell and the renal cell should not be 
difficult. Fatty granules may usually be demon- 
strated in the renal cell. These granules are per- 
haps not to be taken as fatty degeneration but as 
infiltration, a mere substitution, according to Mal- 
lory, of fat for dead proteid. 

The renal cell is always mononuclear, this nucleus 
being dense, globular and centrally situated. The 



120 



PRACTICAL URANALYSES 



true pus cell is polymorphonuclear (in tuberculosis, 
endothelial leucocytes and lymphocytes are also 
present) and these nuclei are eccentrically located 
and irregular in shape. Besides the hyalin-like ap- 
pearance which may be made out at places even in 
the degenerating renal cells, the clear-cut walls or 
cuticulae as well as the flattened, or biscuit-like at- 
tachments to its fellows or the propria may be 
noted. The advice in regard to higher power objec- 
tives should be repeated for emphia^is, for large col- 
lections of renal cells have been mistaken for pus. 
Vesicle Cells. — ^AU cells in the urine, which are 






Fig. 11. — Some typical epithelial cells from the urinary passages. 
A, squamous cell of vagina and urethra; B, caudate cells from pelvis 
of kidney, ureter, and bladder; C, cylindrical cell from the upper por- 
tion of the male urethra; D, polynuclear cell, same origin as tailed cell; 
E> two renal cells. 



not vascular elements, pavement epithelium or re- 
nal epithelium are doubtless from the urinary blad- 
der or ureter. This statement is justified only upon 
the assumption that the physician is always able to 
identify vascular, renal and pavement cells; and is 
suggested by the fact that vesicle cells vary con- 
siderably in their appearance being borderline cells 
between the renal and pavement types. The author 
would hasten to say that the finding of cells appar- 



MICROSCOPIC URANALYSES 121 

ently from the urinary bladder, even in the presence 
of vesicle symptoms, do not carry much diagnostic 
weight, not only because of the fact that similar 
cells may come from the kidney pelvis, but that 
bladder symptoms occur very frequently in connec- 
tion with diseases higher up (scalding urines of 
colipyelitis and renal tuberculosis (see page 136). 

Among the vesicle cells, the chief types are : mul- 
tinucleated, large cells with or without processes, 
the smaller, mononucleated cells with a single or 
double process (tailed cells) and the flat cells. As 
a rule the flat cells may be differentiated from those 
of the urethra or vagina by the fact that they are 
'^rounder," usually smaller and present a more 
homogeneous cytoplasm. They rarely occur in large 
clumps as do the cells of the urethra and vagina. 

Cells From Vagina and Urethra. — These may be 
found in almost every urinary specimen and have 
no clinical significance. They are of the stratified 
squamous, or pavement type. Sometimes singly, 
they usually occur, however, in masses; and the 
units like scales of a fish lie overlapping. The 
larger masses are most likely to come from the 
vagina, but large masses are occasionally found in 
the urine of the male. 

Other Epithelial Cells.— Cubical or cylindrical 
cells are occasionally seen and are derived from the 
prostate, male urethra, gland ducts, and so on. 
Aberrant cells from carcinoma have been identified 
in the urine ; but as a rule it is not safe to make a 
diagnosis of malignant growth upon such premises. 



122 PRACTICAL URANALYSES 

this for the reason that from the bladder or ureter 
almost any type of cell may be desquamated. Car- 
cinoma is diagnosticated in laboratory work, not by 
the actual appearance of the cells, but by the rela- 
tion of certain epithelial cells to connective tissues 
as determined by histotomy. Cells apparently ma- 
lignant may come from a benign bladder papilloma. 

Red Blood Corpuscles. — Fresh specimens should 
be examined. It is better to examine specimens con- 
taining fcAV cells than those saturated with blood, 
since these cells show a tendency to cling into 
masses and obscure other findings as renal cells, 
casts, and so on. Unaltered erythrocytes show the 
characteristic, circular, biconcave form and the 
straw color as observed elsewhere. They are best 
studied in the fresh, acid samples. In alkaline 
urines they are rapidly destroyed. In diluted 
urines, ghosts are usually found; in concentrated 
urines, crenated forms occur. The presence of red 
corpuscles in the sediment is undoubted proof of 
hemorrhage at some point in the urinary tract. It 
is not always easy to determine this point but symp- 
toms, the condition of the corpuscles, the three glass 
test and the reaction of the urine may aid. Blood 
casts point rather conclusively to renal hemorrhage, 
but in many forms of renal hemorrhage, blood casts 
are absent. Then too, blood corpuscles sometimes 
show a tendency to adhere to casts, and a true blood 
cast is proved by demonstrating that blood cells en- 
ter into the makeup of the cast. 

Pus Cells. — The same cautions anent the examina- 



MICROSCOPIC URANALYSES 123 

tion of fresh specimens containing few or moderate 
numbers of cells, is to be repeated here. Pus cells 
may come from the genital organs, and in ques- 
tioned cases it is well to discard the first urine 
voided that this source of error may be eliminated, 
Centrifugalization tends to alter the morphological 
appearance of pus cells, and should be avoided 
where possible. Under the subject of renal cells, 
reference has been made to the appearance of the 
pus cell. It is somewhat larger than the erythro- 
cyte, is granular and multinucleated. The nuclear 
figures can be brought out by the addition of dilute 
acetic acid, but it must be kept in mind that this 
dissolves the granules of the cytoplasm. The pres- 
ence of leucocytes in the carefully prepared urinary 
sediment is evidence of infection in the urinary 
tract. The exact location must be determined by 
other examinations or other findings. Pus casts are 
rarely found and indicate a very grave prognosis. 
Of course they are derived from the kidney. Close 
examination will usually show that the cells are not 
leucocytes but are renal epithelial cells. 

Mononuclear leucocytes (lymphocytes and endo- 
thelial leucocytes) may be present in early renal 
tuberculosis before secondary infection occurs. It 
is not so easy to differentiate these from the renal 
cell. However they possess no cell membrane, and 
the nucleus is very large and oval in shape (round 
in lymphocyte) making up most of the cell. 

Mucus. — In some urines especially when concen- 
trated, mucus threads may be identified. So far as 



124 PRACTICAL URANALYSES 

is known no clinical significance can be attached to 
an increase of the urinary mucus. So-called, 
'^muco-pus" is not true mucus but is alkaline pus. 
When a purulent urine becomes alkaline or when al- 
kalies are added, the pus cells tend to cohere and 
to the naked eye present a mucoid appearance. The 
condition is easily recognized by microscopy and 
need nat confuse. 

True mucus is usually recognized by the micro- 
scopist, providing the illumination is not too in- 
tense. Mayer's mucicarmine which stains all true 
mucus, has been used as a means of differentiation. A 
small amount of mucus is perhaps present in every 
urine, and with the suspended cellular elements 
forms the nubecula, or cloudy deposit. 

Oylindroids. — Cylindroids, or pseudo casts are 
likewise of mucus composition. In highly concen- 
trated urines the number and appearance of the 
mucus strands may give us the impression that we 
are dealing with cylindroids. We are not, for cylin- 
droids are not thread-like ramblings of amorphous 
mucus, but are casts, quite as much so as the true 
casts of hyalin and so on. Once distinguished by 
the careful worker, concentrated mucus will never 
again be mistaken for cylindroids. 

It is the consensus of opinion that amorphous mu- 
cus has no clinical significance. The persistent pres- 
ence of cylindroids must, however, be regarded as 
an item of pathological importance, and it is usually 
he who belittles the cylindroid, whose eye sees in 
every microscopical mucus filament a cylindroid. 



MICROSCOPIC URANALYSES 125 

What is a cylindroid ? The cylindroid is a cast; 
not the so-called true cast described by the texts, 
but a cast, nevertheless — and from the same mold 
that wombs the true hyaline, granular or epithelial 
types; i.e., the uriniferous tubule. 

The cylindroid may be discriminated from other 
casts by two properties : 

1. It is not a perfect cast; for instead of break- 
ing off bluntly at least at one end, it pulls off leav- 
ing pointed or frayed-out ends. 2. It is composed of 
mucus, whereas the others are composed of products 
of degeneration, necrosis, hemorrhage or inflamma- 
tion. There are other discriminating points but for 
practical purposes these two will suffice. Clearly 
the cylindroid does not, like the other casts, denote 
serious alterations in the kidney structure; it has a 
meaning nevertheless. Under what conditions as 
nearly as we can imagine, would such small amounts 
of mucus as are likely to be present in the urinif- 
erous tubule, be likely to form a cast of that tubule? 
The most logical explanation is a very sluggish flow 
of urine through that tubule. 

Products of excretion should be removed as 
quickly as possible from the organism attempting 
to throw them off. It is true of feces (copremia) ; 
it is true of bile (bilirubinemia) ; it is true through- 
out the animal and vegetable kingdoms. Thus we 
find the velocity of urinary flow through the tortu- 
ous secreting kidney tubule very, very slow. It may 
be true that even at Bowman's capsule there was a 
water paucity and a solids overplus, or cells in the 



126 PRACTICAL URANALYSES 

convoluted tube may be taking up some of the wa- 
ter (?) — upon all of these points we cannot def- 
initely commit ourselves. Nevertheless w^e must ac- 
knowledge that for some reason the flow has been 
retarded sufficiently for a mucus cast of that urinif- 
erous tubule to be formed. Mucus is cohesive and 
tractile, and is not very adhesive or brittle (even 
when considerably desiccated) as are the casts com- 
monly referred to as true casts. Thus the charac- 
teristic contour of the cylindroid is easily explained. 

Casts. — By true casts are meant all casts of the 
uriniferous tubule, other than the mucus cast. The 
finding of casts in a urinary sample does not prove 
inflammation. It may point either to an active in- 
flammation (nephritis) or to a secondary kidney 
injury (nephrosis), and we cannot always differen- 
tiate between the two merely by an invoice of the 
number and types of casts. 

In a large number of examinations controlled by 
clinical observation, the author has gained the im- 
pression that serum albumin may appear in the 
urine whether the injury is active or repaired. In 
other words, albuminuria is prone to continue for 
a long period following kidney disease, even though 
there is good reason to believe that the patient has 
recovered. The injury has been such that certain 
portions involved have become unable to prevent 
serum albumin from the blood escaping. Upon the 
other hand the presence of casts seem to indicate 
that injury is taking place at the time of the find- 
ing. However, this does not mean that the presence 



MICROSCOPIC URANALYSES 127 

of casts necessarily spells a progressive or hopeless 
trouble. Cylinder showers often indicate a good 
prognosis — yesterday the cast Avas formed, today 
the flow of urine is increased and the cast is washed 
away. However in many cases the cylinder shower 
(especially granular casts) may precede the fatal 
issue. 

Hyaline casts are simple, true casts. Hyaline like- 
Avise forms the matrix for granules, cells, fat drop- 
lets and so on, which lend individuality to the other 
forms making exceedingly easy cast classification. 
In so many words, all or most all casts which are 
not cylindroids are hyaline casts. What is hyaline? 
We do not know, or at least we cannot agree upon 
a definition. Whence comes the hyaline? It can- 
not be regarded as a normal urinary substance. By 
some it is supposed to represent a local hemorrhage 
— a microscopic extravasation into the lumen of a 
uriniferous tubule with subsequent alterations re- 
sulting in the peculiar translucent appearance and 
brittle make-up. Hyaline gives some peculiar chem- 
ical reactions, but of its actual derivation and com- 
position, we know but little. After all it may prove 
but a modified serum albumin. 

Granular casts are h^^aline casts which have in- 
cluded granules of dying protoplasm (not coagu- 
lated serum albumin, but bits of renal cells). This 
jjrotoplasmic portion of the cast argues strongly for 
retrograde changes. It means that cells lining the 
tubules are undergoing cloudy swelling, then coagu- 
lation necrosis and finally disintegration. These 



128 PRACTICAL URANALYSES 

protoplasmic granules may often be found free in 
severe cases, but when slowly freed tend to be in- 
cluded in the hyaline cast. 

Fatty casts are hyaline casts which have included 
fat droplets in their formation. They represent 
fatty degenerations and consequent freeing of fatty 
granules from the renal cells. Here also in the se- 
vere cases the fatty granules or droplets may ap- 
pear free in the urine. 

The same principles hold in regard to the other 
casts. Entire epithelial cells, pus cells or blood cor- 
puscles are sometimes included in the hyaline ma- 
trix, and the significance respectively is that of the 
finding of each element floating free in the urine. 
Casts are best found and identified by the lower 
powers. They will be missed when the illumination 
is intense — ^narrow the iris diaphragm if you hope 
to find them. 

Cylinder Showers. — The occurrence of the cylin- 
der shower; i.e., the sudden increase in number of 
casts, is not without clinical significance. Such 
cases may be divided into the favorable and un- 
favorable. In the latter the urine is likely to show 
no changes in quantity but may be decreasing, the 
casts are not huge but minute and often imperfect 
showing especially the degenerative types as gran- 
ular, fatty, pigmented, cellular and other forms. 

But the favorable cases show an increasing out- 
put of urine and monster hyalin casts one end of 
which often tapers like the mucus cast. When 
edema is decreasing at the same time, the idea is 



MICROSCOPIC URANALYSES 129 

highly suggestive that the process has been a gen- 
eral ^^ damming back'' and that this is the ^Svash- 
ing out." 

In the favorable cases, moreover, the cylinder 
shower is quickly completed; whereas in the grave 
ones, the casts may persist, or be found to be actu- 
ally increasing in number so long as urine can be 
secured. In either instance the cylinder shower 
may be regarded as a crisis. 

The subject of cylinder showers needs careful 
study. It is unfair to assume, as has been done in 
the past that a sudden increase of these, spells a 
hopeless prognosis in every case. 

Fat Droplets and Granules. — Fat droplets in the 
urine may be pathological or extraneous. They may 
be found after catheterization where a lubricant is 
used. It has been claimed that the smegma may 
contribute an occasional dab of grease. It is well 
to remember that fat metastases often occur after 
fractures especially in the aged, and some of this fat 
may appear in the urine. Those of us who practice 
in the tropics will have to deal with filarial chyluria ; 
but it is doubtful if most of us come into contact 
with cases of lipuria. All of the above mentioned 
fatty urines may be examined by the low power ob- 
jective. It may be ventured that the finding of 
large fat droplets in the urine, usually means con- 
tamination of the specimen with extraneous fat. 

Careful work with the higher powers will often 
demonstrate minute fat droplets (fat granules) us- 
ually within the substance of casts or desquamated 



130 PRACTICAL UR ANALYSES. 

renal sells (pioepitheliiim). Such a finding means 
fatty degeneration of the secreting kidney cells, 
and is very closely identified with cloudy swelling. 
In fact the tAvo processes appear to go hand in hand, 
either meaning acid retention in the protoplasm, 
but the latter also signifying decreased oxygena- 
tion. The fatty change is not truly a degeneration 
but a fat substitution (infiltration) the fatty drop- 
lets taking the place of lost albumin. 

Where the fatty granules occur in large amounts 
they may be found free of the cells or casts. In 
case of question they may be stained by osmic acid 
or Sudan in. 

Spermatozoa. — The spermaturias may be classi- 
fied as accidental, semipathological and patholog- 
ical, though it may not always be easy to distin- 
guish these types clinically. Accidentally, sperma- 
tozoa may be found in the urine voided after coitus. 
Distinctly pathological is the escape of spermatozoa 
secondary to tuberculosis of the prostate gland, dur- 
ing a severe typhoid, in diabetes, and so on. Per- 
haps all cases of spermaturia not accidental are 
truly pathological, but the therapeutist has hoped 
that many of these cases are semipathological (neu- 
rotic). And now and then we must confess to wit- 
nessing cure of an obstinate case Avhere if any or- 
ganic basis were present, it could not be found. The 
explanation may be had in some cases, in the fact 
that these patients are masturbating. 

Occasionally the loss of seminal elements is star- 
tling. The urine may bear the peculiar rank odor, 



MICROSCOPIC URANALYSES 131 

may be turbid and the microscope show hundreds 
of spermatozoa in each field. Notwithstanding the 
presence of the urinary salts, enzymes and other 
substances alien to the spermatozoon, as a rule it is 
motile and remarkably well preserved and may pre- 
sent no characteristics differing from those when 
found in its natural medium. 

Molds and Yeasts. — Pathological molds and 
yeasts are rarely found in the urine. Either may 
occasionally be met as extraneous. Yeasts occur in 
large numbers in diabetic urines undergoing fer- 
mentation of the glucose. Molds in considerable 
quantity frequently come from the vagina where 
especially during pregnancy they often grow in 
large numbers giving rise to a '' scalding leucor- 
rhea. *^ The appearance of yeasts and molds varies 
in no way from that presented elsewhere. Molds 
are identified by their thread-like and branching 
mycelia, and rarely give rise to spores in the urine. 
Yeasts are distinguished by their peculiar budding 
arrangement. Giant yeast cells have sometimes 
been mistaken for pus corpuscles. Careful examina- 
tion will usually show that they bear buds, present 
a sharper outline, contain no nuclei or granules and 
refract light similar to the hyaline cast or renal cell. 

Bacterial Survey. — A freshly voided, normal 
urine should contain few or no bacteria, and espe- 
cially is this true when the first few drops rinsing 
out the urethra have been discarded. When exam- 
ination of a hanging-drop of freshly voided urine 
shows bacteria in appreciable numbers, their pres- 



132 PRACTICAL URANALYSES 

ence is not to be judged unimportant. In colon in- 
fections the specific microorganisms may sometimes 
be found before pus appears. In typhoid fever the 
bacilluria may be so marked that the urine may ap- 
pear to be clouded. Micrococci rarely occur in num- 
bers sufficient to gain attention save by examination 
of stained smears. It may be ventured that as a 
rule a freshly voided urine showing many bacilli 
(even though pus is absent) in which certain types 
predominate or make up the collection is patholog- 
ical and demands careful investigation. It may 
prove to be one of three conditions : 

1. Bacilluria accompanying a general infection, 
as typhoid. 

2. Bacilluria of a urinary infection, as colipyel- 
itis. 

3. Bacilluria of semipathological import but fa- 
voring the formation of urinary calculi or gravel. 

Differentiation will usually depend upon cultural 
methods, animal inoculations or smears. 

A bacteriological survey of a decomposing urine 
is quite valueless. 

Protoplasmic Granules (Epithelial Debris). — This 
sediment has been considered rather thoroughly un- 
der granular casts and elsewhere. It is well to re- 
m.ember that this deposit in the severe kidney dis- 
eases (especially the chronic types) may become 
very marked indeed. To the naked eye it may re- 
semble the white phosphatic sediments. Microscop- 
ically the granules are amorphous. When concen- 
trated and spread they may be stained with bis- 



MICROSCOPIC URANALYSES 133 

marck broAvn. This applies also to the demonstra- 
tion of granules in cells and casts. 

Protoplasmic granules may be distinguished from 
amorphous urates by heating. The former is not af- 
fected but the latter disappears. Careful micro- 
scopy will rule out bacteria. The differentiation 
from earthy phosphates is not so easy, as acid also 
dissolves the protoplasmic granules, though per- 
haps with never the same ease. However, careful 
microscopy and clinical circumstances will differen- 
tiate invariably. 

Extraneous Materials. — Among these are cotton 
fibers, linen fibers, starch grains, fat cells, vegetable 
cells, dirt, hairs, feathers, and so on. It is well to 
avoid contamination of the specimen as much as 
possible, but there should be no difficulty in identi- 
fying these contaminating materials, if the worker 
is grounded in elementary microscopy. 



CHAPTER VI. 
BACTERIOLOGICAL URANALYSES. 

Securing the Sediment. — Aseptic precautions 
must be taken when securing the specimen of urine 
for examination. Catheterization is often necessary 
in the female but is not the method of choice in the 
case of the male inasmuch as the catheter is likely 
to carry in microorganisms from the skin or meatus. 
It is much better to wash the glans and meatus with 
soap and w^arm water, then with 50 per cent ethyl 
alcohol and ask the patient to void his urine. 

The first few drops contain all or most of 
the material which contaminates and should be re- 
jected. The next portion of the voiding may be 
received into a sterile centrifuge tube. The last few 
drops should be rejected, because the muscles sur- 
rounding the urethra are contracting and are likely 
to force material from the glands which might be a 
source of error in bladder and kidney diagnoses. In 
the case of suspected urethral infection, however, 
we save the first and last drops. Cultures or animal 
inoculations may be made directly from the urine 
in the tube or from the sediment gained from cen- 
trifugalization. The latter procedure is usually nec- 
essary for the making of smears. 

Smears. — This is the most rapid method of bac- 
teriological examination, and is of more or less 

134 



BACTERIOLOGICAL URANALYSES 135 

value ill the case of all infections. By smears, Ave 
may identify the gonococcus. This applies also to 
the tubercle bacillus, but it is also advisable to 
make animal inoculations where the smears are neg- 
ative. Colon and typhoid bacilli cannot be abso- 
lutely identified or differentiated by smears alone, 
although the appearance of characteristic rods in 
the fresh urine where the symptoms are almost con- 
clusive, is not without value. 

The sediment is transferred by a sterile pipet to 
a sterile slide. If pus (or mucus) is present in con- 
siderable quantity, smears may be made Avithout 
further ado. But sometimes (and this is especially 
the case in renal tuberculosis) it may be necessary 
to use a fixative to hold the small amount of sedi- 
ment to the slide. The best fixative for this purpose 
is egg albumin Avhich consists of one part of egg- 
Avhite, nine parts of sterile, distilled Avater and 
enough chloroform to saturate to preserve it. The 
sediment Avhen thin is mixed into a drop of this fix- 
ative on a sterile slide and smeared. 

This smear is permitted to dry in the air, fixed 
Avith gentle heat according to standard bacteriolog- 
ical methods and then stained by the Ziehl-Neelson 
method for tubercle bacilli. Gram's method for 
gonococci, and so on. 

Typhoid Bacilli.— In case of suspected typhoid 
bacilluria, the finding of many bacilli in a freshly 
voided urine may be considered strong positiA^e evi- 
dence but of course is not final. Differentiation may 
be made from the colon bacillus bv the tedious cul- 



136 PRACTICAL URANALYSES 

tural tests outlined in works upon bacteriology, and 
which are rarely used by the average practitioner. 

Colon Bacilli.' — The same holds true in regard to 
colon bacilli. The infection may be located in the 
renal pelvis, but the symptoms are often vesicle in 
type due to reflexes or ^ ' scalding. ' ' Often the urine 
is highly acid ; and it may be ventured that as a rule 
an acid pyuria is more likely to be a pyelitis or 
suppurative nephritis than a simple cystitis (re- 
gardless of symptoms). The same holds in tubercu- 
losis of the kidney where the urine may be acid and 
the symptoms vesicle. Furthermore it must be re- 
membered that either colon bacilli or tubercle bacilli 
may appear in the urine before pus is found, and 
have been identified by smears before a pyuria could 
be diagnosticated. 

Gonococci. — The gonococcus is routinely identi- 
fied by smears. A fairly conclusive picture may be 
obtained in the methylene blue stained smear, but 
in case of question, apply the Gram method. By 
this technic the gonococcus is decolorized and takes 
the counter-stain while saprophytes of the coccus 
type and the various pyococci retain the Gram stain. 
A number of Gram technics have been proposed. A 
very simple and satisfactory routine method is as 
follows : 

1. Upon the fixed smear, pour some carbol- 
gentian-violet solution. 

2. After two or three minutes, pour off this stain 
and add at once enough Gram's iodin solution to 
cover the film. It is well to add some fresh iodin 



BACTERIOLOGICAL URANALYSES 137 

solution after a minute. When the '^ coffee- 
grounds'' color appears or when the iodin solution 
has been on for about 90 seconds, wash in water. 

3. Shake off the water and add 95 per cent al- 
cohol, leaving this on the film until no more violet 
color soaks out. 

4. Wash again in water. 

5. Counter-stain with neutral red or fuchsin. 
The gonococci will be stained red and the other bac- 
teria, violet. This method of Gram's staining is re- 
liable and less complicated as no heating is neces- 
sary and permanent staining solutions may be used. 

Gonococci appear free or in the cytoplasm of the 
pus cells as minute twin micrococci, the adjacent 
surfaces someivhat flattened, thus resembling coffee- 
beans. In the chronic cases they are often increased 
in size. They often occur as tetrads, or fours. 

Tubercle Bacilli. — The urine is acid as a rule, and 
may be clear and apparently sterile. Pus finally ap- 
pears, but pus in considerable quantity is usually 
due to secondary infection. The cells first to ap- 
pear are mononuclear in type (endothelial leuco- 
cytes and lymphocytes). It is almost invariably the 
best plan to use a fixative when preparing smears 
in the early cases. These smears are stained by the 
Ziehl-Neelson method because the alcohol decolor- 
izes the smegma bacillus which is likewise acid- 
proof and regarded as a source of error. The Ziehl- 
Neelsen technic is applied as follows : 

1. Stain the fixed smear in hot carbol-fuchsin 
for one or two minutes. 



138 PRACTICAL URANALYSES 

2. Wash in water. 

3. Wash in dilute nitric acid 10-15 seconds or 
until a faint pink just remains in the thinner por- 
tions of the smear. 

4. Wash in 60 per cent alcohol for 10 seconds. 

5. Wash in water. 

6. Counter-stain slightly Avith methylene blue. 

7. Wash in water. 

The tubercle bacilli are stained red and all other 
material and bacteria are stained blue. 

The tubercle bacillus has been grown upon special 
artificial media by inoculating the sediment, but as 
a rule the method is too slow and unreliable for seri- 
ous clinical consideration. 

In suspected tuberculosis of the kidney, it is often 
advantageous to inoculate the cavy with the sedi- 
ment. Animal holders are not needed. An assist- 
ant picks up the pig by his hincL legs, head down- 
Avard. With the other hand he holds the head and 
front feet in such a manner that they will not inter- 
fere^ with the operation. The operator plucks some 
hair from the belly, and cleanses the skin first with 
water and soap and then with 50 per cent alcohol. 
The intraperitoneal injection is the one usually de- 
scribed. The needle should be introduced just at 
tlie edge of the umbilicus. After three weeks the 
pig is killed and autopsied, the peritoneum and 
mesentery being carefully examined for tubercles. 
These may be sectioned in case of question. If the 
pig dies within a few days after inoculation, it is 



BACTERIOLOGICAL URANALYSES 139 

probably by virtue of pyococcus infection, though 
miliary tuberculosis may be the cause. 

Bloch has devised a special technic for the sub- 
cutaneous inoculation. He injects a cubic centi- 
meter of the sediment into the thigh of the cavy, 
massages towards the inguinal glands and pinches 
these somewhat to injure them and lower their re- 
sistance. These glands ma}^ be removed after 10-12 
days and examined for tuberculous infection by 
means of smears or sections, or both. This gives us 
a very rapid method of precise diagnosis of renal 
tuberculosis. 

Less Frequently Met Bacteria. — Among these 
may be mentioned the pathogenic staphylococci 
(pyococci), streptococci, diphtheria bacilli, and 
so on. 



INDEX 



Aceto-acetic acid^ 75 
Acetone, 76 

Acidity of the urine, 39 
Albumin, serum, 44 

detection of, 46 

estimation of, 98 
Albuminuria, 44 
Albumose, 53 
Alimentary albuminuria, 44 

glucosuria, 64 
Alkalinity of the urine, 40 
Amino acids, 91, 113 
Ammonia, 91 
Ammoniacal urine, 15, 109 
Ammonium-magnesium phos- 
phate, 109 
Ammonium urate, 109 
Amorphous urates, 108 
Amount of urine, 25 
Arabinose, 72 

B 

Bacteriological uranalyses, 134 
Bence-Jones body, 53 
Bile acids, 61 
Bile pigments, 58 
Bilirubin, 58 

Blood, chemical tests, 54 . 
microscopy, 122 

C 

Calcium carbonate, 110 
oxalate, 110 
phosphate, 109 
sulphate, 112 



Cancer cells, 122 
Carbon dioxid, 16, 110 
Casts, all types, 126-128 
Centrifugalization, 105 
Chlorides, estimation of, 88-90 
Chondroitic acid, 43 
Cole test for glucose, 68 
Colon bacillus, 136 
Color of urine, 27 
Cylinder showers, 128 
Cylindroids, 124 
Cystin, 112 

D 

Diabetes, 64 

Diacetic acid, 75 

Diazo test, 81-84 

Drugs, effects on urine, 19 

E 

Earthy phosphates, 109 
Epithelial casts, 128 
Epithelium, various types, 115- 

121 
Esbach estimation of albumin, 

98 
Ethereal sulphates, 91 
Euglobulin, 42 



Pat droplets and granules, 129 
Fatty casts, 128 
Fermentation test for glucose, 

68, 100 
Functional albuminuria, 44 



141 



142 



INDEX 



G 

Globulin, 53 

Glucose, estimation of, 100-103 

tests for, 66 
Gonococcus, 136 
Gout, uric acid in, 95 
Granular casts, 128 
Granules, protoplasmic, 132 
Gravel, 97, 110 

H 

Hematuria, 55 
Hemoglobinuria, 54 
Hyaline casts, 126 



Indie an, 77, 80 
Indolacetic acid, 80 
Inorganic acids, 36 
Iodine in urine, 79 



Lactose, 74 
Leucin, 113 



N 



Nitric acid test, 47 
Nitrogen, 91 
Nubecula, 104 

O 

Odor of the urine, 28 
Oliguria, 27 
Orcin test, 72 
Organic acids, 36 
Oxalates, 110 
Oxybutyric acid, 74 

P 

Pancreatic lesions, 65 
Pathological albuminuria, 44 
Pentose, 72 
Phosphates, 109 



Pioepithelium, 130 
Polyuria, 26 
Pus, 122, 128 

Q 

Quantitative uranalyses, 87 
Quantity of urine, 25 

E 

Keaction of urine, 39 
Eenal cells, 115 
Eenal glucosuria, 65 
Eusso test, 84 

S 

Sacchari meter, 100 
Serum albumin, 44 
Serum globulin, 53 
Specific gravity, 32 
Staphylococci, 139 
Sulphates, 91, 112 



Titration, 37, 89 
Triple phosphates, 109 
Tubercle bacillus, 137 
Tyrosin, 113 

U 

Unorganized sediments, 107 
Urates, 108 
Urea, 88, 93 
Ureometer, 94 
Uric acid, 88, 95, 108 
Urinometer, 32 
Urobilinogen, 63 
Urochromogen, 80 



Variations in composition, 15- 
23 



Xanthin, 86 



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